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Table of Contents    
Year : 2011  |  Volume : 59  |  Issue : 1  |  Page : 131-132

Intermittent herniation of brain: A rare cause of intermittent cerebrospinal fluid rhinorrhea

Imaging Sciences & Interventional Radiology, SCTIMST, Thiruvananthapuram, Kerala, India

Date of Submission29-Oct-2010
Date of Decision30-Oct-2010
Date of Acceptance01-Nov-2010
Date of Web Publication18-Feb-2011

Correspondence Address:
Chandrasekharan Kesavadas
Imaging Sciences & Interventional Radiology, SCTIMST, Thiruvananthapuram, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.76871

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How to cite this article:
Sen A, Kesavadas C. Intermittent herniation of brain: A rare cause of intermittent cerebrospinal fluid rhinorrhea. Neurol India 2011;59:131-2

How to cite this URL:
Sen A, Kesavadas C. Intermittent herniation of brain: A rare cause of intermittent cerebrospinal fluid rhinorrhea. Neurol India [serial online] 2011 [cited 2023 Nov 30];59:131-2. Available from:


We report a case of a 48-year-old female who presented with complaints of intermittent episodes of watery discharge from right nostril since 4-5 months, which increased on bending forward and on straining. There was no history of headache, vomiting, visual symptom or head injury. Neurological and ophthalmological examinations were normal.

Plain CT through the anterior cranial fossa showed opacification inferior to expected position of right cribriform plate [Figure 1]a. No leak could be demonstrated in the CT cisternography. MRI done after 2 weeks during an asymptomatic (no rhinorrhea) period revealed herniation of right gyrus rectus [Figure 1]b. Repeat MRI performed at the time of active cerebrospinal fluid (CSF) leak showed the right gyrus rectus to be in a slightly lower position compared to left side, but there was no significant herniation of brain [Figure 2]a. Fluid appeared to extend below the cribriform plate level on right side [Figure 2]b, c and d. Empty sella [Figure 2]e and bilateral mildly prominent perioptic nerve sheath fluid [Figure 2]f was also noted.
Figure 1: (a) Coronal CT bone window image shows opacification (white arrow) inferior to expected position of right cribriform plate. (b) T2- weighted turbo spin echo coronal image shows herniation (white arrow) of right gyrus rectus

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Figure 2: (a and b) T2-weighted turbo spin echo coronal images and (c and d) CISS(constructive interference in steady state) coronal images show right gyrus rectus to be in slightly lower position (white arrow) compared to left side, but with no significant herniation; Fluid (arrow-head) noted below expected position of right cribriform plate consistent with CSF leak. (e and f) T2-weighted turbo spin echo images: (e) sagittal section shows empty sella (white arrow) and (f) coronal section shows bilateral prominent perioptic nerve sheath fluid (black arrows)

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We presume that herniation of brain had sealed the site of leak at the time of first MRI, leading to stoppage of leak. Later, in the second MRI done when the rhinorrhea recurred, the site was not plugged with herniated brain.

Patient had a temporary cessation of CSF rhinorrhea lasting for a few weeks following lumbar puncture on two occasions: first time after the CT cisternography and second time after lumbar puncture done for ruling out meningitis. Decrease in CSF pressure after LP may have caused sagging of brain and herniation of gyrus rectus, leading to plugging of osteodural defect and cessation of CSF rhinorrhea. To the best of our knowledge, intermittent cerebral herniation leading to intermittent CSF rhinorrhea has not been reported previously.

There have been case reports regarding intracranial hypertension as etiology of CSF rhinorrhea [1],[2] and encephalocele. [2] But in our case, other than empty sella and mildly prominent perioptic nerve sheath fluid, other classical radiological signs of intracranial hypertension such as vertical buckling of optic nerve and flattening of the posterior sclera were absent. Empty sella has a 60% incidence [3] in spontaneous CSF rhinorrhea and 76% incidence in females with spontaneous CSF rhinorrhea. In our patient there was no clinical suspicion of intracranial hypertension or evidence of papilloedema.

Since the rate of CSF fistula detection is significantly low in patients without active leak compared to patients with active leak, [4] many institutions by protocol, image CSF leaks only during periods of active leak. Our case indicates that imaging during asymptomatic period also may have some value and may throw light on the cause of 'intermittency' of CSF leaks. In particular, role of intracranial pressure in the etiology and intermittency of CSF leaks needs to be studied.

 » References Top

1.Saifudheen K, Gafoor A, Arun G, Abdurahiman P, Jose J. Idiopathic intracranial hypertension presenting as CSF rhinorrhea. Ann Indian Acad Neurol 2010;13:72-3.  Back to cited text no. 1
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2.Deepak KS, Kesavadas C, Kapilamoorthy TR, Menon G. Cerebrospinal fluid rhinorrhoea and acquired anterior basal encephalocele in a patient with colloid cyst of the third ventricle. Neurol India 2010;58:156-8.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Schuknecht B, Simmen D, Briner HR, Holzmann D. Nontraumatic skull base defects with spontaneous CSF rhinorrhea and arachnoid herniation: Imaging findings and correlation with endoscopic sinus surgery in 27 patients. AJNR Am J Neuroradiol 2008; 29:542-9.  Back to cited text no. 3
4.El Gammal T, Sobol W, Wadlington VR, Sillers MJ, Crews C, Fisher WS 3rd, et al. Cerebrospinal fluid fistula: Detection with MR cisternography. AJNR Am J Neuroradiol 1998;19:627-31.  Back to cited text no. 4


  [Figure 1], [Figure 2]

This article has been cited by
1 Letters to the Editor. Idiopathic intracranial hypertension presenting solely as CSF rhinorrhea
Anitha Sen
Journal of Neurosurgery. 2014; 121(3): 765
[Pubmed] | [DOI]
2 Intermittent herniation of brain causing intermittent cerebrospinal fluid rhinorrhea
Saifudheen, K.
Neurology India. 2011; 59(3): 493
3 Authorsę reply
Sen, A., Kesavdas, C.
Neurology India. 2011; 59(3): 493-494


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