Answer for BIR CoW 17 Mar 2024
IDIOPATHIC INTRACRANIAL HYPERTENSION WITH SPONTANEOUS CSF RHINORRHEA
Findings
T2 3D SPACE sequences showed a hyperintense tract extending from the floor of the anterior cranial fossa into the left posterior paranasal sinuses. Scattered T2 hyperintensity was also seen in the left spheno ethmoid recess, superior aspect of the nasal cavity bilaterally below cribriform plates. MRI Brain showed empty sella filled with CSF. Dilated peri optic nerve sheaths were seen. Non-contrast MR Venogram showed stenosis of bilateral transverse sinuses. In addition, T2 images also showed multiple sites of prominent arachnoid imprints at the skull base. Spine screening showed meningoceles at a few levels.
Discussion
CSF Rhinorrhea is a symptom of cerebrospinal fluid leakage into the paranasal sinuses, then into the nasal cavity with the patient presenting with clear nasal discharge, exacerbating on bending forward. Congenital causes include meningocele, encephalocele, and persistent lateral cricopharyngeal canal. In most acquired cases, it is a result of trauma or surgery causing osseous, dural defects in the skull base leading to communication between the intracranial compartment and nasal cavity via paranasal sinuses. However, in our case, there was no such history. So, a diagnosis of spontaneous CSF rhinorrhea was given with idiopathic intracranial hypertension as the causative factor. Possible defects were reported at cribriform plates bilaterally, and peri sellar site. The patient was taken up for endoscopic surgery, active leak was visualized on the left side from a defect at the cribriform plate with a small meningocele. Dural patch repair was done in addition to the ventriculoperitoneal shunt to relieve the raised intracranial tension. Non-traumatic spontaneous CSF rhinorrhea is a rare occurrence with idiopathic intracranial hypertension as a common and important etiology. The most common sites of spontaneous CSF leak are the cribriform plate, ethmoid roof, sphenoid sinus, peri sellar region, and pterygoid recess. Pathophysiology has been described to be the persistently raised intra-cranial pressure causing skull base erosions at weak spots leading to meningo encephaloceles. These erosions are visualized in the form of arachnoid imprints in the skull base on MRI. This acts as a protective mechanism against permanently elevated intracranial tension.
Findings
T2 3D SPACE sequences showed a hyperintense tract extending from the floor of the anterior cranial fossa into the left posterior paranasal sinuses. Scattered T2 hyperintensity was also seen in the left spheno ethmoid recess, superior aspect of the nasal cavity bilaterally below cribriform plates. MRI Brain showed empty sella filled with CSF. Dilated peri optic nerve sheaths were seen. Non-contrast MR Venogram showed stenosis of bilateral transverse sinuses. In addition, T2 images also showed multiple sites of prominent arachnoid imprints at the skull base. Spine screening showed meningoceles at a few levels.
Discussion
CSF Rhinorrhea is a symptom of cerebrospinal fluid leakage into the paranasal sinuses, then into the nasal cavity with the patient presenting with clear nasal discharge, exacerbating on bending forward. Congenital causes include meningocele, encephalocele, and persistent lateral cricopharyngeal canal. In most acquired cases, it is a result of trauma or surgery causing osseous, dural defects in the skull base leading to communication between the intracranial compartment and nasal cavity via paranasal sinuses. However, in our case, there was no such history. So, a diagnosis of spontaneous CSF rhinorrhea was given with idiopathic intracranial hypertension as the causative factor. Possible defects were reported at cribriform plates bilaterally, and peri sellar site. The patient was taken up for endoscopic surgery, active leak was visualized on the left side from a defect at the cribriform plate with a small meningocele. Dural patch repair was done in addition to the ventriculoperitoneal shunt to relieve the raised intracranial tension. Non-traumatic spontaneous CSF rhinorrhea is a rare occurrence with idiopathic intracranial hypertension as a common and important etiology. The most common sites of spontaneous CSF leak are the cribriform plate, ethmoid roof, sphenoid sinus, peri sellar region, and pterygoid recess. Pathophysiology has been described to be the persistently raised intra-cranial pressure causing skull base erosions at weak spots leading to meningo encephaloceles. These erosions are visualized in the form of arachnoid imprints in the skull base on MRI. This acts as a protective mechanism against permanently elevated intracranial tension.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!