This is the first time I have come across this kind of a report.Can anyone help me as how to code this report?
CT CISTERNOGRAMS OF THE CRANIAL CAVITY:
Clinical information: H/O squamous cell cancer of right eyelid
with intraorbital extension. right orbital exenteration and right
fronto-spheno-temporal craniectomy. Postop- CSF rhinorrhea
(leakage into the right nasal cavity).
The patient was placed in the prone position on the X-ray table.
Through the intraspinal drainage tube approximately 4 cc of Isovue
300 mg% was injected into the spinal canal. The tip of the
intrathecal catheter was seen in the upper thoracic spinal canal.
The contrast material was seen in the cervical and thoracic spinal
Subsequently the X-ray table was tiled in head-down position,
allowing the contrast material to gravitate into the cranial
cavity. Then the patient was transported to the CT room in a
stretcher in the prone position.
On the CT table, helical axial scans of the head were acquired in
the prone position at 3 mm interval. these were then
reconstructed into 1 mm scan slices. Coronal and sagittal
reformatted images were created.
There is evidence of right fronto-spheno-temporal craniectomy and
right orbital exenteration. A reconstructive myocutaneous flap is
noted at the surgical site. There is evidence of resection of the
right frontal sinus. The crista galli is intact.
The contrast material is seen in the subarachnoid spaces in the
anterior cranial fossa, interhemispheric fissure and other basal
A tiny bony defect is seen in the posterior wall of the right
frontal sinus, on the right side of the crista galli, measuring
1.5 mm in diameter. This tiny bony defect allows the contrast
material to enter the right frontal sinus as seen on image #65,
series #602. Less dense contrast material is seen filling the left
frontal sinus. The right nasofrontal duct is dense, so is the
right middle nasal turbinate, indicating layering of contrast
material, as seen on image #22, series 603.
Minimal fluid collections are seen in bilateral maxillary sinuses.
But there is no evidence of contrast material in either maxillary
sinus. The ethmoid and sphenoid sinuses are clear.
1. CSF leakage through a tiny bony defect in the posterior wall
of the right frontal sinus, on the right side of the crista galli.
2. Status post right fronto-spheno-temporal craniectomy and right
orbital exenteration with a reconstructive myocutaneous flap at
the surgical site.
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