Case Author(s): Lester S. Johnson, M.D., Ph.D. and Farrokh Dehdashti, M.D. , 11/15/99 . Rating: #D2, #Q4

Diagnosis: cerebral spinal fluid leak

Brief history:

Chronic rhinorrhea subsequent to ENT surgery


A right lateral image is shown.

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View second image(cl). An anterior view of the abdomen at 24 hours post injection

Full history/Diagnosis is available below

Diagnosis: cerebral spinal fluid leak

Full history:

This 57 year old woman had a nasal polyp removed four years ago. Two years ago, she began noticing clear rhinorrhea whenever she bent over. Initially the fluid came from her left nostril, but now it occurs bilaterally. This study was requested to rule out a CSF leak.


0.532 mCi In-111 DTPA, lumbar subarachnoid injection


Images of the head were obtained 6 and 20 hours after injection. Normal tracer activity is present in the basal cisterns. In addition, tracer extends inferiorly and anteriorly into the nasopharynx and nose. This abnormal distribution of tracer is consistent with a CSF leak. An anterior image of the abdomen demonstrates activity within the stomach and bowel, likely as a result of swallowing CSF that had leaked into the nasopharynx.


Prior to injection of the radiopharmaceutical, the patient underwent placement of pledgets in the nasal cavity. Cotton pledgets were placed bilaterally in the apices of the nasal cavity, in the superior meatus, and in the middle meatus. After the 6 hour images were obtained, the nasal pledgets were removed, weighed, and counted in vitro along with a simultaneously obtained plasma sample. The ratio of the pledget activity (counts/g accumulated fluid) to that of the plasma activity (counts/ml) was extremely elevated in all left-sided pledgets. This ratio was moderately elevated in the superior and middle pledgets on the right side and normal in the inferior right-sided pledget. These data, together with the images, indicate the presence of a CSF leak into the nasopharynx bilaterally, left greater than right.

ACR Codes and Keywords:

References and General Discussion of Cerebral Spinal Fluid Leak (Anatomic field:Skull and Contents, Category:Effect of Trauma)

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Case number: cl002

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