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A 66-year-old woman presented with sudden onset of sixth nerve palsy and back pain after an episode of intense coughing as a result of a prolonged severe upper respiratory tract infection. Radiologic investigation did not reveal a space-occupying lesion. An MRI of the thoracic spine was reported as not demonstrating a cerebrospinal fluid leak. A radionuclide cerebrospinal fluid study was performed to identify a suspected leak and demonstrated an unusual pattern of multiple leaks at the midthoracic level. Review of the MRI then revealed a leak confirming the value of radionuclide cisternography in localizing the anatomic site of a cerebrospinal fluid leak not initially demonstrated on MRI.