Evaluation of high-resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula.

PURPOSE: We undertook this study to determine the accuracy of MR cisternography and plain high-resolution CT as a noninvasive alternative to CT cisternography in the diagnosis of CSF fistula in patients with clinically suspected CSF rhinorrhea.

METHODS: Forty-five consecutive patients with clinically suspected CSF rhinorrhea were examined prospectively for CSF fistula with MR cisternography and plain high-resolution CT. Twenty-one patients also underwent CT cisternography. The MR imaging technique included 3-mm thin-section T1-weighted coronal sequences and fast spin-echo T2-weighted coronal, axial, and sagittal sequences in the supine position. The plain high-resolution CT study included 3-mm and sometimes 1- to 1.5-mm thin coronal sections in the prone position. Similar sequences were used after injecting nonionic contrast material intrathecally via lumbar puncture for the CT cisternographic study. The plain high-resolution CT and MR cisternographic studies were compared with results of CT cisternography; surgical findings were used as the standard of reference.

RESULTS: Plain high-resolution CT successfully depicted the presence or absence of CSF fistula in 42 of 45 patients, whereas MR cisternography was correct in 40 patients. MR cisternography or plain high-resolution CT correctly showed the site(s) of CSF fistula leakage in 36 of the 38 cases proved surgically. The combined techniques also correctly indicated the absence of CSF leakage in seven cases, six of which were confirmed at CT cisternography. Both MR cisternography and high-resolution CT failed to definitively locate the CSF fistula in two patients. High-resolution CT was accurate in 93% of patients, whereas MR cisternography was accurate in 89% of patients. The combination of high-resolution CT and MR cisternography was accurate in 96% of patients.

CONCLUSION: In the presence of clinically diagnosed CSF leakage, the combination of MR cisternography and plain high-resolution CT is highly accurate in locating the site and extent of CSF fistula and should be considered a viable noninvasive alternative to CT cisternography.