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Osawa I, Mitsufuji T, Nagawa K, Hara Y, Yamamoto T, Araki N, Kozawa E. Comparing 2-dimensional versus 3-dimensional MR myelography for cerebrospinal fluid leak detection. Eur J Radiol Open 2024; 12:100565. [PMID: 38699593 PMCID: PMC11063600 DOI: 10.1016/j.ejro.2024.100565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
Purpose We compared cerebrospinal fluid (CSF) leak conspicuity and image quality as visualized using 3D versus 2D magnetic resonance (MR) myelography in patients with spinal CSF leaks. Methods Eighteen patients underwent spinal MR imaging at 3 Tesla. Three board-certified radiologists independently evaluated CSF leak conspicuity and image quality on a 4-point scale; the latter assessed by scoring fat suppression, venous visualization, and severity of CSF flow artifacts. Additionally, the evaluators ranked the overall performances of 2D versus 3D MR myelography upon completing side-by-side comparisons of CSF leak conspicuity. Inter-reader agreement was determined using the Gwet's AC1. Results The quality of 3D MR myelography images was significantly better than that of 2D MR myelography with respect to CSF leak conspicuity (mean scores: 3.3 vs. 1.9, p < 0.0001) and severity of CSF flow artifacts on the axial view (mean scores: 1.0 vs. 2.5, p = 0.0001). Inter-reader agreement was moderate to almost perfect for 2D MR myelography (AC1 = 0.55-1.00), and almost perfect for 3D MR myelography (AC1 = 0.85-1.00). Moreover, 3D MR myelography was judged to be superior to 2D acquisition in 78 %, 83 %, and 83 % of the samples per readers 1, 2 and 3, respectively; the inter-reader agreement was almost perfect (AC1: reader 1 vs. 2; 0.98, reader 2 vs. 3; 0.96, reader 3 vs. 1; 0.98). Conclusion CSF leaks are more conspicuous when using 3D MR myelography than when using its 2D counterpart; therefore, the former is more reliable for identifying such leaks.
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Affiliation(s)
- Iichiro Osawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Takashi Mitsufuji
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Keita Nagawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Yuki Hara
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Toshimasa Yamamoto
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Nobuo Araki
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Eito Kozawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
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Lee SJ, Kim D, Suh CH, Shim WH, Heo H, Jo S, Chung SJ, Kim HS, Kim SJ. Detection rate of MR myelography without intrathecal gadolinium in patients with newly diagnosed spontaneous intracranial hypotension. Clin Radiol 2022; 77:848-854. [PMID: 35985843 DOI: 10.1016/j.crad.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/16/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the detection rate of magnetic resonance (MR) myelography without intrathecal gadolinium for cerebrospinal fluid (CSF) leakage in patients with newly diagnosed spontaneous intracranial hypotension (SIH) and to validate a published scoring system for predicting CSF leakage. MATERIALS AND METHODS This retrospective, observational, single-institution study included patients with newly diagnosed SIH between March 2015 and April 2021. Patients were included if they (a) had newly diagnosed SIH and (b) underwent initial brain MR imaging and preprocedural MR myelography with two- and three-dimensional turbo spin-echo sequences. Patients who underwent spine surgery or procedures including epidural injection and acupuncture were excluded. The detection rate was defined as the proportion of patients with a true-positive MR myelography result among all patients with confirmed CSF leakage. The interobserver agreement for the MR myelography results between two radiologists was analysed using weighted kappa statistics. RESULTS A total of 136 patients (mean age, 48 years; 70 women) with suspected SIH were included. Of these patients, 120 (88%, 120/136) were confirmed to have CSF leakage. Of the patients with confirmed CSF leakage, 90 (75%, 90/120) had epidural fluid collection. The detection rate of MR myelography for CSF leakage was 88% (105/120). The interobserver agreement between the two readers for detecting CSF leakage (κ = 0.76) or epidural fluid collection (κ = 0.76) on MR myelography was high. Among 24 patients with normal brain MR imaging results, 16 had CSF leakage (67%, 16/24). CONCLUSIONS Non-invasive MR myelography without intrathecal gadolinium should be considered to detect CSF leakage in patients with suspected SIH.
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Affiliation(s)
- S J Lee
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D Kim
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C H Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - W H Shim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - H Heo
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S Jo
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S J Chung
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - H S Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S J Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension: a systematic review and meta-analysis. Eur Radiol 2022; 32:7843-7853. [PMID: 35538263 DOI: 10.1007/s00330-022-08845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To investigate the pooled diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension (SIH). METHODS A literature search of the MEDLINE/PubMed and Embase databases was conducted until July 25, 2021, including studies with the following inclusion criteria: (a) population: patients with newly diagnosed SIH; (b) diagnostic modality: MR myelography or MR myelography with intrathecal gadolinium for evaluation of CSF leakage; (c) outcomes: diagnostic yield of MR myelography or MR myelography with intrathecal gadolinium. The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects modeling was used to calculate the pooled estimates. Subgroup analysis regarding epidural fluid collection and meta-regression were additionally performed. RESULTS Fifteen studies with 643 patients were included. Eight studies used MR myelography with intrathecal gadolinium, and 11 used MR myelography. The overall quality of the included studies was moderate. The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) and that of MR myelography with intrathecal gadolinium was 83% (95% CI, 51-96%). There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium (p = 0.512). In subgroup analysis, the pooled diagnostic yield of the epidural fluid collection was 91% (95% CI, 84-94%). In meta-regression, the diagnostic yield was unaffected regardless of consecutive enrollment, magnet strength, or 2D/3D. CONCLUSIONS MR myelography had a high diagnostic yield in patients with SIH. MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium. KEY POINTS • The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) in patients with spontaneous intracranial hypotension. • There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium. • MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.
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Osawa I, Kozawa E, Mitsufuji T, Yamamoto T, Araki N, Inoue K, Niitsu M. Intravenous enhanced 3D FLAIR imaging to identify CSF leaks in spontaneous intracranial hypotension: Comparison with MR myelography. Eur J Radiol Open 2021; 8:100352. [PMID: 34026946 PMCID: PMC8134034 DOI: 10.1016/j.ejro.2021.100352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/27/2021] [Accepted: 05/08/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose To evaluate the clinical utility of intravenous gadolinium-enhanced heavily T2-weighted 3D fluid-attenuated inversion recovery (HT2-FLAIR) imaging for identifying spinal cerebrospinal fluid (CSF) leaks in patients with spontaneous intracranial hypotension (SIH). Methods Patients with SIH underwent MR myelography and post-contrast HT2-FLAIR imaging after an intravenous gadolinium injection. Two types of CSF leaks (epidural fluid collection and CSF leaks around the nerve root sleeve) at each vertebral level were compared between the 2 sequences. The total numbers of CSF leaks and vertebral levels involved were recorded for the whole spine. The sequence that was superior for the overall visualization of epidural and paraspinal fluid collection was then selected. Results Nine patients with SIH were included in the present study. HT2-FLAIR imaging was equivalent or superior to MR myelography at each level for detecting the 2 types of CSF leaks. In the 2 types of CSF leaks, the total numbers of CSF leaks and levels involved were higher on HT2-FLAIR images than on MR myelography, while no significant difference was observed for CSF leaks around the nerve root sleeve. In all 9 patients, HT2-FLAIR imaging was superior to MR myelography for the overall visualization of epidural and paraspinal fluid collection. Conclusion Intravenous gadolinium-enhanced HT2-FLAIR imaging was superior to MR myelography for the visualization of CSF leaks in patients with SIH. This method can be useful for identifying spinal CSF leaks.
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Key Words
- CHESS, Chemical shift selective
- CSF, Cerebrospinal fluid
- FLAIR, Fluid-attenuated inversion recovery
- HT2-FLAIR, Heavily T2-weighted fluid-attenuated inversion recovery
- Heavily T2-weighted 3D FLAIR
- Intravenous gadolinium-enhanced MR imaging
- MIP, Maximum intensity projection
- MPR, Multiplanar reconstruction
- MR myelography
- MRI, Magnetic resonance imaging
- SIH, Spontaneous intracranial hypotension
- Spinal cerebrospinal fluid leak
- Spontaneous intracranial hypotension
- T1W, T1-weighted
- T2W, T2-weighted
- TSE, Turbo spin echo
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Affiliation(s)
- Iichiro Osawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
- Corresponding author at: 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan.
| | - Eito Kozawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Takashi Mitsufuji
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Toshimasa Yamamoto
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Nobuo Araki
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Kaiji Inoue
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Mamoru Niitsu
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
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Dobrocky T, Winklehner A, Breiding PS, Grunder L, Peschi G, Häni L, Mosimann PJ, Branca M, Kaesmacher J, Mordasini P, Raabe A, Ulrich CT, Beck J, Gralla J, Piechowiak EI. Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences. AJNR Am J Neuroradiol 2020; 41:1309-1315. [PMID: 32554417 DOI: 10.3174/ajnr.a6592] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/06/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spine MR imaging plays a pivotal role in the diagnostic work-up of spontaneous intracranial hypotension. The aim of this study was to compare the diagnostic accuracy of unenhanced spine MR imaging and intrathecal gadolinium-enhanced spine MR imaging for identification and localization of CSF leaks in patients with spontaneous intracranial hypotension. MATERIALS AND METHODS A retrospective study of patients with spontaneous intracranial hypotension examined from February 2013 to October 2017 was conducted. Their spine MR imaging was reviewed by 3 blinded readers for the presence of epidural CSF using 3 different sequences (T2WI, 3D T2WI fat-saturated, T1WI gadolinium). In patients with leaks, the presumed level of the leak was reported. RESULTS In total, 103 patients with spontaneous intracranial hypotension (63/103 [61%] women; mean age, 50 years) were evaluated. Seventy had a confirmed CSF leak (57/70 [81%] proved intraoperatively), and 33 showed no epidural CSF on multimodal imaging. Intrathecal gadolinium-enhanced spine MR imaging was nonsuperior to unenhanced spine MR imaging for the detection of epidural CSF (P = .24 and .97). All MR imaging sequences had a low accuracy for leak localization. In all patients, only 1 leakage point was present, albeit multiple suspicious lesions were reported in all sequences (mean, 5.0). CONCLUSIONS Intrathecal gadolinium-enhanced spine MR imaging does not improve the diagnostic accuracy for the detection of epidural CSF. Thus, it lacks a rationale to be included in the routine spontaneous intracranial hypotension work-up. Heavily T2-weighted images with fat saturation provide high accuracy for the detection of an epidural CSF collection. Low accuracy for leak localization is due to an extensive CSF collection spanning several vertebrae (false localizing sign), lack of temporal resolution, and a multiplicity of suspicious lesions, albeit only a single leakage site is present. Thus, dynamic examination is mandatory before targeted treatment is initiated.
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Affiliation(s)
- T Dobrocky
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - A Winklehner
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - P S Breiding
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - L Grunder
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - G Peschi
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
- Department of Interventional, Pediatric, and Diagnostic Radiology (G.P., J.K.)
| | - L Häni
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
| | - P J Mosimann
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - M Branca
- Clinical Trials Unit (M.B.), University of Bern, Bern, Switzerland
| | - J Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
- Department of Interventional, Pediatric, and Diagnostic Radiology (G.P., J.K.)
| | - P Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - A Raabe
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
| | - C T Ulrich
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
| | - J Beck
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
- Department of Neurosurgery (J.B.), Medical Center, University of Freiburg, Freiburg, Germany
| | - J Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - E I Piechowiak
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
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Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension. AJR Am J Roentgenol 2016; 206:8-19. [DOI: 10.2214/ajr.15.14884] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Ducros A, Biousse V. Headache arising from idiopathic changes in CSF pressure. Lancet Neurol 2015; 14:655-68. [DOI: 10.1016/s1474-4422(15)00015-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 12/24/2022]
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Roos C. Ipotensione intracranica spontanea. Neurologia 2015. [DOI: 10.1016/s1634-7072(14)69822-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Rai PVS, Santosh K, Chakraborti S, Pai S, Keerthi I, Pai MK. A blast from the past!: The value of adding single slice magnetic resonance myelography sequence to magnetic resonance imaging of the spine; a flashback to the conventional myelography of the past. Surg Neurol Int 2014; 5:S523-8. [PMID: 25593771 PMCID: PMC4287895 DOI: 10.4103/2152-7806.148018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 09/16/2014] [Indexed: 12/05/2022] Open
Abstract
Background: The study was undertaken to determine whether a single slice magnetic resonance (MR) myelogram sequence improves the interpretation and diagnostic yield for magnetic resonance imaging (MRI) of the spine. Methods: A total of 100 cases with positive findings were retrospectively reviewed. All patients had initial imaging with sagittal T1-weighted (T1-W) and T2-weighted (T2-W) scans, followed by axial T2-W images. Subsequently, a heavily T2-W single slice MR myelogram sequence was acquired in coronal and sagittal planes. The MR myelogram images were evaluated initially by a radiologist, and, further independently reviewed, by a neurologist, neurosurgeon, and spine surgeon. The utility of the MR myelogram in establishing the diagnosis was graded on a 4-point scale. Results: Out of 100 cases, 53% showed degenerative spine or disc disease, 14% space occupying lesions, 13%, congenital lesions, 7% infection, and 7% other conditions. The MR myelogram contributed additional information in 50-74% cases. The intraclass correlation coefficient showed overall good agreement between observers in grading the utility of MR myelogram. Conclusion: Single slice MR myelography is noninvasive avoiding the complications associated with lumbar punctures/intrathecal contrast injections, while image acquisition takes only an added 6-8 s. Although MR myelogram has no value as a stand-alone sequence, its inherent advantage is that it completes the overview of the spinal pathology in entirety, and adds vital three-dimensional information in 50-74% of cases.
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Affiliation(s)
- P V Santosh Rai
- Department of Radiodiagnosis, Kasturba Medical college, Manipal University, Mangalore, Karnataka, India
| | - K Santosh
- Department of Radiodiagnosis, Kasturba Medical college, Manipal University, Mangalore, Karnataka, India
| | - Shrijeet Chakraborti
- Department of Pathology, Kasturba Medical college, Manipal University, Mangalore, Karnataka, India
| | - Shivananda Pai
- Department of Neurology, Kasturba Medical college, Manipal University, Mangalore, Karnataka, India
| | - Ishwara Keerthi
- Department of Spine Surgery, Kasturba Medical college, Manipal University, Mangalore, Karnataka, India
| | - Muralidhar K Pai
- Department of Neurosurgery, Kasturba Medical college, Manipal University, Mangalore, Karnataka, India
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Abstract
A literature search found no clinical trials or guidelines addressing the management of spontaneous intracranial hypotension (SIH). Based on the available literature and expert opinion, we have developed recommendations for the diagnosis and management of SIH. For typical cases, we recommend brain magnetic resonance (MR) imaging with gadolinium to confirm the diagnosis, and conservative measures for up to two weeks. If the patient remains symptomatic, up to three non-directed lumbar epidural blood patches (EBPs) should be considered. If these are unsuccessful, non-invasive MR myelography, radionuclide cisternography, MR myelography with intrathecal gadolinium, or computed tomography with myelography should be used to localize the leak. If the leak is localized, directed EPBs should be considered, followed by fibrin sealant or neurosurgery if necessary. Clinically atypical cases with normal brain MR imaging should be investigated to localize the leak. Directed EBPs can be used if the leak is localized; non-directed EBPs should be used only if there are indirect signs of SIH.
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Sakurai K, Matsukawa N, Okita K, Nishio M, Shimohira M, Ozawa Y, Kobayashi S, Yamawaki T, Shibamoto Y. Lumbar puncture-related cerebrospinal fluid leakage on magnetic resonance myelography: is it a clinically significant finding? BMC Anesthesiol 2013; 13:35. [PMID: 24160550 PMCID: PMC4175475 DOI: 10.1186/1471-2253-13-35] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 10/25/2013] [Indexed: 11/24/2022] Open
Abstract
Background Post-dural puncture headache (PDPH) due to excessive cerebrospinal fluid (CSF) leakage is a well-known complication of lumbar puncture. Although various factors, especially the type of spinal needle, have been demonstrated to be associated with PDPH, the clinical implications of CSF leakage detected on magnetic resonance myelography (MRM) images remain unclear. The objective of this case–control study was to evaluate the association between radiologically visualized CSF leakage and PDPH. Methods Clinical data including patients’ age and gender, types of spinal needle, duration of bed rest, interval between lumbar puncture procedures and MRM studies, and incidence of PDPH were compared between patients who were radiologically-positive and -negative for CSF leakage. Results Of the 22 patients with definite CSF leakage on MRM images, most were asymptomatic (86%, 19/22). The remaining three patients, who were suffering from PDPH, only complained of headaches and were treated conservatively. In a review of patients’ clinical data, there were no significant differences in any parameter including the incidence of PDPH between the 22 patients who were radiologically-positive for CSF leakage and the 31 radiologically-negative patients. Conclusion The significance of radiologically visualized CSF leakage should not be overestimated, as most such incidents are not associated with PDPH and do not require any treatment.
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Affiliation(s)
- Keita Sakurai
- Department of Diagnostic Radiology, Tokyo Metropolitan Medical Center of Gerontology, 35-2 Sakaecho, Itabashi-ku, Tokyo 173-0015, Japan.
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Epstein NE. A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery. Surg Neurol Int 2013; 4:S301-17. [PMID: 24163783 PMCID: PMC3801173 DOI: 10.4103/2152-7806.111427] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/25/2013] [Indexed: 02/06/2023] Open
Abstract
Background: In spinal surgery, cerebrospinal fluid (CSF) fistulas attributed to deliberate dural opening (e.g., for tumors, shunts, marsupialization of cysts) or inadvertent/traumatic dural tears (DTs) need to be readily recognized, and appropriately treated. Methods: During spinal surgery, the dura may be deliberately opened to resect intradural lesions/tumors, to perform shunts, or to open/marsupialize cysts. DTs, however, may inadvertently occur during primary, but are seen more frequently during revision spinal surgery often attributed to epidural scarring. Other etiologies of CSF fistulas/DTs include; epidural steroid injections, and resection of ossification of the posterior longitudinal ligament (OPLL) or ossification of the yellow ligament (OYL). Whatever the etiology of CSF fistulas or DTs, they must be diagnosed utilizing radioisotope cisternography (RIC), magnetic resonance imaging (MRI), computed axial tomography (CT) studies, and expeditiously repaired. Results: DTs should be repaired utilizing interrupted 7-0 Gore-Tex (W.L. Gore and Associates Inc., Elkton, MD, USA) sutures, as the suture itself is larger than the needle; the larger suture occludes the dural puncture site. Closure may also include muscle patch grafts, dural patches/substitutes (bovine pericardium), microfibrillar collagen (Duragen: Integra Life Sciences Holdings Corporation, Plainsboro, NJ), and fibrin glues or dural sealants (Tisseel: Baxter Healthcare Corporation, Deerfield, IL, USA). Only rarely are lumbar drains and wound-peritoneal and/or lumboperitoneal shunts warranted. Conclusion: DTs or CSF fistulas attributed to primary/secondary spinal surgery, trauma, epidural injections, OPLL, OYL, and other factors, require timely diagnosis (MRI/CT/Cisternography), and appropriate reconstruction.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurological Surgery, Department of Neurosurgery, The Albert Einstein College of Medicine, Bronx, NY, 10461, and Chief of Neurosurgical Spine and Education, Department of Neurosurgery, Winthrop University Hospital, Mineola, NY, 11501, USA
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HOSOYA T, HATAZAWA J, SATO S, KANOTO M, FUKAO A, KAYAMA T. Floating Dural Sac Sign is a Sensitive Magnetic Resonance Imaging Finding of Spinal Cerebrospinal Fluid Leakage. Neurol Med Chir (Tokyo) 2013; 53:207-12. [DOI: 10.2176/nmc.53.207] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Takaaki HOSOYA
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine
| | - Jun HATAZAWA
- Department of Nuclear Medicine, Osaka University Graduate School of Medicine
| | - Shinya SATO
- Department of Neurosurgery, Yamagata University Faculty of Medicine
| | - Masafumi KANOTO
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine
| | - Akira FUKAO
- Department of Public Health, Yamagata University Graduate School of Medicine
| | - Takamasa KAYAMA
- Department of Neurosurgery, Yamagata University Faculty of Medicine
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Abstract
The spinal canal is frequently a source of difficulties, traps and diagnostic errors. Pitfalls related to artifacts are resolved by using appropriate sequences. Good knowledge of the appearance of certain particular anatomical structures (the cauda equina roots, the radicular veins of the lumbar spine and conus medullaris, the dorsal root ganglion) and of frequent variants (fibrolipoma of the filum terminale, common root sheaths, root cysts) will avoid a good many errors. Dilatation of epidural veins in intracranial hypotension can simulate the contrast enhancement of a tumour. An increase in epidural fat can induce pathogenic stenosis of the dural sheath.
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Sakurai K, Nishio M, Yamada K, Shimohira M, Ozawa Y, Matsukawa N, Oguri T, Ueki Y, Tohyama J, Yamawaki T, Shibamoto Y. Comparison of the radioisotope cisternography findings of spontaneous intracranial hypotension and iatrogenic cerebrospinal fluid leakage focusing on chronological changes. Cephalalgia 2012; 32:1131-9. [PMID: 22990687 DOI: 10.1177/0333102412459571] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radioisotope cisternography (RICG) is useful for detecting cerebrospinal fluid (CSF) leakage in spontaneous intracranial hypotension (SIH) patients. However, RICG can cause iatrogenic CSF leakage (ICSFL) due to a lumbar puncture. OBJECTIVES To compare the RICG findings of SIH and ICSFL. METHODS The presence of direct findings suggesting CSF leakage and indirect findings including early visualization of the bladder and absence of radioactivity over the brain convexities were evaluated in seven SIH and six ICSFL patients. Radioisotope clearance was assessed semi-quantitatively. RESULTS In contrast to the variety of anatomical levels at which direct findings were detected in the SIH patients, the ICSFL patients only displayed direct findings at the lumbosacral level. None of the ICSFL patients displayed direct findings at 1 hour after the tracer injection. Although early visualization of the bladder was depicted in all patients, no activity was visualized over the brain convexities in the SIH patients. In the semi-quantitative analysis, the tracer retention index at 24 hours was lower in the SIH patients than the ICSFL patients. CONCLUSIONS The early appearance of direct findings above the lumbosacral level, the absence of radioactivity over the brain convexities and a low tracer retention index are suggestive of SIH.
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Affiliation(s)
- Keita Sakurai
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Japan.
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17
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Detection of CSF leaks with magnetic resonance imaging in intracranial hypotension syndrome. J Neuroradiol 2011; 38:175-7. [DOI: 10.1016/j.neurad.2010.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Revised: 10/20/2010] [Accepted: 11/08/2010] [Indexed: 11/24/2022]
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18
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Dissociation between the severity of cerebrospinal fluid hypovolemia and MRI findings. J Neurol 2009; 257:665-6. [DOI: 10.1007/s00415-009-5416-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Accepted: 11/24/2009] [Indexed: 11/25/2022]
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19
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Abstract
Since the introduction of magnetic resonance imaging (MRI), spontaneous intracranial hypotension has been diagnosed much more frequently. The aim of this review is to discuss the symptoms and signs of the condition, in particular the characteristics of the associated headache, with sudden onset after sitting or standing, so that it can be included under the rubric of 'thunderclap headache'. This type of headache, like post lumbar puncture headaches, may be caused by cerebral vasodilatation and exacerbated by lowered pressure of the cerebrospinal fluid (CSF). Other symptoms include neck stiffness, nausea, vomiting, vertigo, tinnitus, deafness, and cognitive abnormalities. The clinical picture can sometimes mimic frontotemporal dementia, and the behaviour of some patients can sometimes be described as hypoactive-hypoalert, with somnolence, impaired attention, and stereotyped motor activity. Sagging of the brain, caused by leakeage of the CSF, can cause lesions in the brainstem with stupor, gaze palsies, and cranial nerve palsies. The condition can be a risk factor for cerebral venous thrombosis because of slowing of the blood flow and distortion of the blood vessels. The clinical picture may well suggest the diagnosis, but the headache may possibly indicate a subarachnoid haemorrhage. However, MRI will help to confirm the diagnosis and to localize the site of the CSF leak. MRI myelograms are of particular value, but if they are equivocal a computed tomography myelogram should be performed. The leakage of CSF is due to a tear in the dura, most frequently where the spinal roots leave the subarachnoid space. If this does not heal with bedrest, an epidural blood patch or a percutaneous injection of fibrin glue may be needed. More information is required on long-term follow-up.
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Contrast-enhanced MR myelography in spontaneous intracranial hypotension: description of an artefact imitating CSF leakage. Eur Radiol 2009; 19:1799-808. [DOI: 10.1007/s00330-009-1347-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 01/03/2009] [Accepted: 01/12/2009] [Indexed: 11/25/2022]
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