nSAIDs and aspirin . This coronal CT cisternogram was obtained after an intrathecal injection of contrast material (Omnipaque 300, 8 mL) into the lumbar thecal sac and subsequent positioning of the contrast agent in the head. official website and that any information you provide is encrypted From the third ventricle, the fluid circulates into the forth ventricle and out into the subarachnoid space via the foramina of Magendie and Luschka. The ring is a result of the different densities of blood and CSF, and is concerning for a basilar skull fracture." While the presence of a double ring sign (sometimes called a halo sign) is often cited as indicating the presence of CSF ( Sapira's Art and Science of Bedside Diagnosis. In 1981, Wigand reported on the use of the endoscope to assist with the repair of a skull base defect. Utility of preoperative high-resolution CT and intraoperative image guidance in identification of cerebrospinal fluid leaks for endoscopic repair. Conclusion: Cerebrospinal fluid (CSF) leaks are generally classified as traumatic, iatrogenic, and spontaneous/idiopathic. J Neurotrauma. 2015 Apr 28. This study may also be useful for detecting inactive fistulas, intermittent leaks, or suspected meningoencephaloceles. The use of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid rhinorrhea. [QxMD MEDLINE Link]. CT cranial cisternography is performed with injection of 5-7 mL of nonionic myelographic contrast medium into the lumbar subarachnoid space. FREE shipping Etsy's Pick Add to Favorites Two-finger Ring Stainless Steel Glasses, Unisex stainless Ring, Double . CSF represents the end product of the ultrafiltration of plasma across epithelial cells in the choroid plexus lining the ventricles of the brain. Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid?. Any surgical manipulation near the skull base can result in an iatrogenic CSF leak. Kevin C Welch, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic SocietyDisclosure: Nothing to disclose. Follow-up 48- or 72-hour scans are possible with 111In and may be useful in the detection of intermittent CSF fluid leaks. 2014 Jul;15(4):363. doi: 10.5811/westjem.2014.4.21346. The 'ring sign': is it a reliable indicator for cerebral spinal fluid Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. [QxMD MEDLINE Link]. [19]. 83(987):225-32. Physical examination should include complete rhinologic (including endoscopic), otologic, head and neck, and neurologic evaluations. Images in emergency medicine. Michael G D'Antonio, MD Associate Professor of Clinical Radiology, Department of Radiology, Section of Neuroradiology, Louisiana State University Health Sciences Center in New Orleans; Consulting Staff Radiologist, Jefferson Radiology Associate, Inc, West Jefferson Medical CenterDisclosure: Nothing to disclose. CSF and blood disseminate at different rates due to different fluid densities creating a double ring with blood surrounded by a ring of CSF. A possible cause of a delayed traumatic leak is a previously intact dural layer that has slowly herniated through a bony defect, finally tearing and allowing the cerebrospinal fluid (CSF) to leak. Double ring sign. Dynamic CT myelography is recommended in these patients, with the injection of the iodinated contrast medium intrathecal on the CT scan table with immediate spine CT scan. official website and that any information you provide is encrypted Thank you for your interest in spreading the word on CMAJ. Radionuclide cisternography may be useful to detect an intermittently active CSF fistula. Basal skull fracture should be considered in all patients with head injuries, especially those with physical signs such as otorrhea, Battle sign or periorbital ecchymoses.1 The halo or double-ring sign is a classic image in medicine and was taught as a method for determining whether bloody discharge from the ears or nose contained cerebrospinal fluid (CSF). However, an astute clinician noted the double ring sign on the stretcher sheet, as noted in the Figure 1. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. Brain Sci. Otolaryngol Head Neck Surg. Also, it serves as nutrient delivery and waste removal system for the brain. Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. Conservative management consists of a 7-10 day trial of bed rest with the head of the bed elevated approximately 15-30. 2023 Mar 10;59(3):540. doi: 10.3390/medicina59030540. [QxMD MEDLINE Link]. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. [20, 21, 22, 23] This technique is based on the intrinsic T2 contrast between CSF and adjacent structures. Griauzde J, Gemmete JJ, Pandey AS, Chaudhary N. Intrathecal preservative-free normal saline challenge magnetic resonance myelography for the identification of cerebrospinal fluid leaks in spontaneous intracranial hypotension. A thorough history is the first step toward accurate diagnosis. The fluid can be placed on filter paper and a "halo" or double ring may be seen. 110(7):1166-72. [QxMD MEDLINE Link]. CSF produced at the choroid plexus typically circulates from the lateral ventricles to the third ventricle via the aqueduct of Sylvius. Federal government websites often end in .gov or .mil. Meningoencephaloceles usually present in childhood as an intranasal/extranasal mass that transilluminates and expands with crying (Furstenberg sign). Radionuclide cisternography is performed by administering a lumbar subarachnoid intrathecal injection of Indium-111 (111In) diethylenetriamine pentaacetic acid (DTPA) in a 500 Ci dose. Curr Opin Otolaryngol Head Neck Surg. 2016 Jan;6(1):8-16. doi: 10.1002/alr.21637. Spontaneous intracranial hypotension syndrome in a patient with chronic headaches, which began after lumbar puncture. 8600 Rockville Pike Defects in the closure of the anterior neuropore can result in the herniation of central nervous tissue through anterior cranial fossa. MeSH 1997. [QxMD MEDLINE Link]. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Br J Neurosurg. Albayram S, Kilic F, Ozer H, Baghaki S, Kocer N, Islak C. Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. Neuroradiology. Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons El Gammal T, Sobol W, Wadlington VR, et al. Skull Base Fracture - an overview | ScienceDirect Topics The benefit of early lumbar drain insertion in reducing the length of CSF leak in traumatic rhinorrhea. [QxMD MEDLINE Link]. Even if the tumor itself does not lead to CSF rhinorrhea, the resection typically results in immediate leakage. Bethesda, MD 20894, Web Policies 2015 Oct 14. Coronal CT image of the temporal bone demonstrates a bone defect (small arrows) in the tegmen tympani with a protruding soft-tissue meningoencephalocele (large arrows). 26(7):628-9. Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists HEENT: nose Flashcards | Quizlet Epub 2018 Sep 24. Double Ring Sign: CSF mixed with blood or nasal discharge forms two rings because CSF being a watery fluid invades linen more than blood called the double-ring sign, halo sign, or . Lobo BC, Baumanis MM, Nelson RF. Results: The type of filter paper did not affect the development of a ring. Drops of fluid from a CSF leak placed on absorbent filter paper may result in the double-ring sign, a central circle of blood and an outer clear ring of CSF. Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of MedicineDisclosure: Nothing to disclose. Share cases and questions with Physicians on Medscape consult. Baltimore: Lippincott, Williams & Wilkins; 2003. Radiol Clin North Am. eCollection 2023 Feb. The site is secure. The most common anatomic sites of spontaneous cerebrospinal fluid (CSF) leaks are the areas of congenital weakness of the anterior cranial fossa and areas related to the type of surgery performed. Acute posttraumatic cerebrospinal fluid rhinorrhea. An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus. However, even in this situation, exceptions can occur. 2009 Oct. 72(4):341-5; discussion 346. Managing cerebrospinal fluid rhinorrhea after lateral skull base surgery via endoscopic endonasal eustachian tube closure. For otorrhea, 1 cotton pledget is placed in each external auditory canal. Enrique Palacios, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. The dura of the anterior cranial base is subject to wide variations in CSF pressure because of several factors, including normal arterial and respiratory fluctuations. High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. [QxMD MEDLINE Link]. The cerebral dural venous sinuses may be engorged. Typically, the leak is caused by either spontaneous dural dehiscence or dural tears caused by degenerative causes. A high rate of fistula detection may be possible with imaging in the prone position, but this may be uncomfortable for the patient. Higher-level studies are needed to better determine optimal diagnostic and clinical management approaches. Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. A variety of cisternographic studies may be necessary to localize some spinal CSF fistulas. 2009 Jul. Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the sclera of the eyes; joint stiffness with difficulty moving or straightening the arms, hands, legs, or feet; pain deep in the hips or ribs; and muscle weakness. [QxMD MEDLINE Link]. The ring sign: Is it a reliable indicator for cerebral spinal fluid? In patients undergoing endoscopic sinus surgery, the site of injury is most frequently the lateral lamella of the cribriform plate, where the bone of the anterior skull base is thinnest. DeConde AS, Suh JD, Ramakrishnan VR. I absolutely agree that not having a double ring sign does not exclude a CSF leak. Preoperative Medical Treatment for Patients With Acromegaly: Yes or No? With one method, the average total time for coronal and sagittal imaging is 48 minutes. Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR Professor Emeritus of Radiology, Louisiana State University Health Sciences Center, New Orleans; Clinical Professor of Radiology, Tulane University School of Medicine doi: 10.1371/journal.pntd.0004516. [11] In contrast to unilateral rhinorrhea, bilateral rhinorrhea gives no clue of the laterality of the defect. The embryologic defect is typically a patent fonticulus frontalis or foramen cecum. Pledgets are placed close to the cribriform plate, in the middle meatus, and in the sphenoethmoidal recess of the right and left nasal cavities. ), She stated that the cerebrospinal fluid (CSF) double ring sign raises concern about a CSF leak. 835-9. Unauthorized use of these marks is strictly prohibited. Various other authors, including Dohlman (1948), Hirsch (1952), and Hallberg (1964), subsequently reported successful repair of CSF rhinorrhea through different external approaches. The type of filter paper did not affect the development of a ring. Some error has occurred while processing your request. Chiapparini L, Farina L, D'Incerti L, et al. CT findings associated with cerebrospinal fluid leaks include fractures or other bone defects; meningocele; focal fluid accumulation in the ethmoid air cells; frontal, sphenoid, or maxillary sinuses or mastoid air cells; and, sometimes, pneumocephalus. Miss Emily Ann King WedsMr. Craig Anthony Przyborski Please enable it to take advantage of the complete set of features! 30(4):399-405. Would you like email updates of new search results? CTA, MRA, or digital subtraction cerebral and cervical arteriography may then be necessary. Conclusion: The entire spine is scanned up to 24 hours in cases of spontaneous intracranial hypotension, spinal trauma, or postoperative CSF leaks. [8]. 2015 May. Perform high-resolution, thin-section axial and coronal cranial and facial computed tomography (CT) scanning. Image demonstrates increased tracer accumulation in the nasal region (arrow). [10]. Since then, endoscopic repair has become the preferred method of addressing CSF rhinorrhea, given the high success rate of 90-95% and the decreased morbidity associated with this approach. Laryngoscope. [QxMD MEDLINE Link]. Before AJR Am J Roentgenol. 1-7. Outcomes of outpatient endoscopic repair of cerebrospinal fluid rhinorrhea. The specificity is almost 100% for contemporary radionuclide cisternography. Computed tomography (CT) of the patients head showed, among other injuries, a transverse fracture of the petrous segment of his right temporal bone (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.120055/-/DC1). Cerebrospinal fluid rhinorrhoea in closed head injuries. Otolaryngology procedures, including FESS and septoplasty, can lead to a skull base defect and CSF rhinorrhea. Ann Nucl Med. Alternatively, with the patient lying prone on a stretcher, the patient's hips can be raised above the level of the head for 1-2 minutes to concentrate the contrast medium over the anterior and posterior regions of the skull base. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Joseph M Scianna, MD Co-Director of Sinus and Sleep Disorders, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical CenterJoseph M Sciannais a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Rhinologic Society, Srinivas Mukkamala, MD Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Loyola University of Chicago Medical Center. The patient is maintained in the prone position until a CT scan is performed. Imaging findings were correlated with both the clinical findings and nasal pledget counts obtained as part of this study. Am J Rhinol Allergy. HHS Vulnerability Disclosure, Help [14]. 1979 Oct 25;97(40):1814-20. MRI in the Localization of CSF Fistulae: Is It of Any Value?. A control pledget for lacrimal secretions is placed under one inferior nasal turbinate. The image also shows a right-sided meningocele (large arrow) protruding through the cribriform plate, which was not suspected but was surgically repaired at the same time as the left cribriform cerebrospinal fluid leak site. Hence, the surgical team should be prepared to repair the resulting CSF leak at the time of the resection, either transcranially or endoscopically. NSF/NFD is a debilitating and sometimes fatal disease. This terminology seems to imply that spontaneous CSF leaks are idiopathic in nature; however, recent evidence has led us to realize that spontaneous CSF rhinorrhea may in reality be secondary to an intracranial process, namely elevated intracranial pressure (ICP). These symptoms also occur in multiple common conditions and so should be evaluated by an ENT specialist if they are not easily explained or do not clear up on their own in a week or so. This site needs JavaScript to work properly. 2020;42[12]:31; http://bit.ly/2HVJcdt. The 'Ring Sign': Is it a reliable indicator for cerebral spinal fluid? 1998 Apr. [29]. Byrne JV, Ingram CE, MacVicar D, et al. 2016 Mar 17;10(3):e0004516. 29 (3):207-10. Neuroradiology. 2011 May. The enzymatic breakdown or destruction of the bony architecture results in inflammation and potential violation of the dura. Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Postoperative Period following Pituitary and Ventral Skull Base Surgery. Background: Obstructive sleep apnea in patients undergoing endoscopic surgical repair of cerebrospinal fluid rhinorrhea. Okizaki A, Shuke N, Aburano T, Hashizume K, Nakai H, Tanaka T. Detection of cerebrospinal fluid leak by dual-isotope spect with In-111 DTPA and Tc-99m HMDP. Accessibility [QxMD MEDLINE Link]. According to another theory, the tear and bony defect are present from the time of the original injury, but the leak occurs only after the masking hematoma dissolves. Matsumura A, Anno I, Kimura H, Ishikawa E, Nose T. Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography. 2016 Mar. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption and the patients written consent for publication. Jinkins JR, Rudwan M, Krumina G, Tali ET. ISSN 1488-2329 (e) 0820-3946 (p). Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. 52:768-770. Basilar Skull Fracture: What Is It, Causes, Symptoms, and More - Osmosis Clinical Pearls: Cerebrospinal Fluid Double Ring Sign Ann Emerg Med. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. -2 transferrin is a protein found in CSF, but not in serum, nasal secretions, or adjacent tissue. Other local services are: Electrical . Epub 2021 Aug 2. Diagnostic Nuclear Medicine. J Neurol Neurosurg Psychiatry. Bonnie Kaplan, MD, showed a picture of blood leaking from the ear of an injured patient onto a bed sheet, which forms a double ring sign, in the December Quick Consult. 1-6 The clinical value of this sign as described in trauma texts must be considered anecdotal because no Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. 2008 Jan. 29(1):116-21. C Douglas Phillips, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, Radiological Society of North AmericaDisclosure: Nothing to disclose. [2] (See the images below. Int Forum Allergy Rhinol. [QxMD MEDLINE Link]. CSF fistula can usually be demonstrated by using some method of cisternography. The site is secure. AJNR Am J Neuroradiol. Cerebrospinal fluid (CSF) leak: Symptoms, treatment, and more 33:690-94. Patients with recurrent meningitis, especially pneumococcal meningitis, should be evaluated for a defect that exposes the intracranial space to the upper airway, regardless of the presence or absence of CSF rhinorrhea. (Ann Emerg Med. An Analysis of Patients Treated for Cerebrospinal Fluid Rhinorrhea in the United States from 2002 to 2010. Spontaneous CSF rhinorrhea usually manifests in adulthood, coinciding with a developmental rise in CSF pressure with maturity. [Full Text]. An absorptive sponge pad placed at or near the presumed site of fluid leak can facilitate the collection of the fluid. 2015 Sep. 123 (3):732-6. 2nd edition. Lu X, Zhai X, Li H, Yang X, Hang W, Liu G. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele. 2001 Aug. 43(8):622-7. All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). BMJ Case Rep. 2017 Apr 22;2017:bcr2016218995. Serum glucose, chloride,. Digital subtraction cisternography: a new approach to fistula localisation in cerebrospinal fluid rhinorrhoea. Nadieska Caballero, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic SocietyDisclosure: Nothing to disclose. Yousry I, Forderreuther S, Moriggl B, et al. Please refer to Etiology for further details. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. CSF Rhinorrhoea - www.medicoapps.org Fluid leaking from the nose or external auditory canal must first be positively identified as CSF. CSF is produced at a rate of approximately 20 mL/h for a total of approximately 500 mL daily. All authors agreed on recommendations through an iterative process. AJNR Am J Neuroradiol. Each patient subsequently underwent a procedure for an epidural blood patch, and all patients experienced symptomatic relief. [Full Text]. [QxMD MEDLINE Link]. Obstructive sleep apnea (OSA) has also been linked to elevated ICP. Fast CSF leaks have rapid contrast diffusion and may not be localized to a 2-vertebral segment of the spinal canal (suitable for local treatment by extradural blood patch or alternate therapy) by routine postmyelogram CT spine scan. 2015 Jan-Feb. 29 (1):77-81. CSF rhinorrhea following a traumatic injury is classified as immediate (within 48 hours) or delayed. Cisternography with an intrathecal injection of radioisotope or nonionic iodinated myelographic contrast medium or MRI cisternography usually localizes the CSF leak. 2003 Aug. 129(8):859-63. Magnetic resonance myelogram in a patient with a brachial plexus injury and pseudomeningoceles (arrows). Clin Radiol. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Extradural fluid collections are common in spinal CSF leak. Hegazy HM, Carrau RL, Snyderman CH, et al. (Ann Emerg Med. You may be trying to access this site from a secured browser on the server. NSF/NFD has occurred in patients with moderate to end-stage renal disease who have been given a gadolinium-based contrast agent to enhance MRI or MRA scans. The probe indicates that access to the defect is performed through the maxillary sinus and pterygopalatine fossa. Surgical repair of skull base defects resulting in cerebrospinal fluid (CSF) rhinorrhea is contraindicated in any patient who is not medically stable to undergo a general anesthetic or comply with postoperative care. Disruption of the barriers between the sinonasal cavity and the anterior and middle cranial fossae is the underlying factor leading to the discharge of CSF into the nasal cavity. All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries. Cerebrospinal fluid imaging. Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Sagittal magnetic resonance myelogram demonstrates a traumatic cerebrospinal fluid leak (small arrows) with disruption of the ligamentum flavum posteriorly (large arrow). [QxMD MEDLINE Link]. HHS Vulnerability Disclosure, Help The leak almost never recurs. doi: 10.1136/bcr-2016-218995. This finding is consistent with a meningoencephalocele of the temporal bone. A halo pattern on a bedsheet produced by bloody otorrhea from a 27-year-old man who had been in a motor vehicle collision. Cerebrospinal fluid (CSF) leak may occur from the nose (rhinorrhea), from the external auditory canal (otorrhea), or from a traumatic or operative defect in the skull or spine. Lucien M Levy, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. eCollection 2016 Mar. Anterior 48-hour scintigraphic image demonstrates tracer accumulation in the right nasal region. Spinal MRI findings are also potentially reversible after successful ablation of a CSF fistula. Cerebrospinal fluid (CSF) rhinorrhea is a rare but potentially devastating condition that can lead to significant morbidity and mortality for the patient. Clin Nucl Med. Halo sign (target sign or double ring sign), when the CSF Rhinorrhea is blood-stained and dries out, a central bloodstain surrounded by a clear ring is seen. Please enable it to take advantage of the complete set of features! [QxMD MEDLINE Link]. An official website of the United States government. Find many great new & used options and get the best deals for DOUBLE HEART FILIGREE .925 Sterling SILVER Ring - 1.5g Size 7.5 at the best online prices at eBay! Methods: ENT emergencies Flashcards | Quizlet [QxMD MEDLINE Link]. Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). [QxMD MEDLINE Link]. Algin O, Hakyemez B, Gokalp G, Ozcan T, Korfali E, Parlak M. The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea. A defect in the skull base is measured with a sterile ruler. 51(6):704, 706. [9]. We reviewed 68 studies examining 9 practices pertinent to the diagnosis of CSF rhinorrhea, with a highest aggregate grade of evidence of C. The literature does not support the use of the ring sign, glucose testing, radionuclide cisternography (RNC), or computed tomography cisternography (CTC) for identification of CSF leak. double-ring sign (Figure 1B). Clin Neurol Neurosurg. [QxMD MEDLINE Link]. 5 Testing fluid from the ear or nose for -2 transferrin is the recommended method to assess patients for a cranial CSF leak because this approach is noninvasive as well as highly sensitive and specific. 30 (6):424-9. These nsignatures together form a ring signature on behalf of pk. Coronal fast spin-echo T2-weighted image demonstrates herniation of meninges and brain tissue (arrows) with adjacent cerebrospinal fluid into the postmastoidectomy tegmen tympani defect. There may be apparent downward displacement of the optic chiasm.

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