Gadolinium in tears: Evidence for an alternative cerebrospinal fluid absorption pathway in the setting of ischemia-induced blood brain barrier disruption

Cerebral ischemia results in disruption of the blood-brain barrier (BBB) allowing leakage of gadolinium-based contrast media (GBCM) into cerebrospinal fluid (CSF) within the craniospinal and perineural subarachnoid spaces (SAS). This phenomenon is well visualized with fluid-attenuated inversion recovery MRI techniques and allows for visualization of CSF flow dynamics. We present a case of ischemia-induced BBB disruption resulting in accumulation of GBCM in the SAS and ocular chambers as well as within the precorneal tear film and nasolacrimal duct. We present imaging evidence for a hypothetical alternate CSF absorption pathway through the ocular structures in keeping with prior experimental evidence. •Leakage of gadolinium-based contrast media into CSF can be seen in the setting of blood-brain barrier disruption.•CSF circulation and flow dynamics may be studied in cases of GBCM leakage.•GBCM accumulation in ocular structures and the tear film suggests presence of an alternate CSF absorption pathway.