1
|
Mark IT, Karki P, Cutsforth-Gregory J, Brinjikji W, Madhavan AA, Messina SA, Cogswell PM, Chen JJ, Ehman RL, Huston J, Murphy MC. Evaluation of MR Elastography as a Noninvasive Diagnostic Test for Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2024; 45:662-667. [PMID: 38485194 DOI: 10.3174/ajnr.a8162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/03/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension is a condition resulting from a leak of CSF from the spinal canal arising independent of a medical procedure. Spontaneous intracranial hypotension can present with normal brain MR imaging findings and nonspecific symptoms, leading to the underdiagnosis in some patients and unnecessary invasive myelography in others who are found not to have the condition. Given the likelihood that spontaneous intracranial hypotension alters intracranial biomechanics, the goal of this study was to evaluate MR elastography as a potential noninvasive test to diagnose the condition. MATERIALS AND METHODS We performed MR elastography in 15 patients with confirmed spontaneous intracranial hypotension from September 2022 to April 2023. Age, sex, symptom duration, and brain MR imaging Bern score were collected. MR elastography data were used to compute stiffness and damping ratio maps, and voxelwise modeling was performed to detect clusters of significant differences in mechanical properties between patients with spontaneous intracranial hypotension and healthy control participants. To evaluate diagnostic accuracy, we summarized each examination by 2 spatial pattern scores (one each for stiffness and damping ratio) and evaluated group-wise discrimination by receiver operating characteristic curve analysis. RESULTS Patients with spontaneous intracranial hypotension exhibited significant differences in both stiffness and damping ratio (false discovery rate-corrected, Q < 0.05). Pattern analysis discriminated patients with spontaneous intracranial hypotension from healthy controls with an area under the curve of 0.97 overall, and the area under the curve was 0.97 in those without MR imaging findings of spontaneous intracranial hypotension. CONCLUSIONS Results from this pilot study demonstrate MR elastography as a potential imaging biomarker and a noninvasive method for diagnosing spontaneous intracranial hypotension, including patients with normal brain MR imaging findings.
Collapse
Affiliation(s)
- Ian T Mark
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Pragalv Karki
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | | | - Waleed Brinjikji
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Steven A Messina
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Petrice M Cogswell
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - John J Chen
- Department of Neurology (J.C.-G., J.J.C.), Mayo Clinic, Rochester, Minnesota
- Department of Ophthalmology (J.J.C.), Mayo Clinic, Rochester, Minnesota
| | - Richard L Ehman
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - John Huston
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Matthew C Murphy
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
2
|
Schwartz FR, Kranz PG, Malinzak MD, Cox DN, Ria F, McCabe C, Harrawood B, Leithe LG, Samei E, Amrhein TJ. Myelography Using Energy-Integrating Detector CT Versus Photon-Counting Detector CT for Detection of CSF-Venous Fistulas in Patients With Spontaneous Intracranial Hypotension. AJR Am J Roentgenol 2024; 222:e2330673. [PMID: 38294163 DOI: 10.2214/ajr.23.30673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND. CSF-venous fistulas (CVFs), which are an increasingly recognized cause of spontaneous intracranial hypotension (SIH), are often diminutive in size and exceedingly difficult to detect by conventional imaging. OBJECTIVE. This purpose of this study was to compare energy-integrating detector (EID) CT myelography and photon-counting detector (PCD) CT myelography in terms of image quality and diagnostic performance for detecting CVFs in patients with SIH. METHODS. This retrospective study included 38 patients (15 men and 23 women; mean age, 55 ± 10 [SD] years) with SIH who underwent both clinically indicated EID CT myelography (slice thickness, 0.625 mm) and PCD CT myelography (slice thickness, 0.2 mm; performed in ultrahigh-resolution mode) to assess for CSF leak. Three blinded radiologists reviewed examinations in random order, assessing image noise, discernibility of spinal nerve root sleeves, and overall image quality (each assessed using a scale of 0-100, with 100 denoting highest quality) and recording locations of the CVFs. Definite CVFs were defined as CVFs described in CT myelography reports using unequivocal language and having an attenuation value greater than 70 HU. RESULTS. For all readers, PCD CT myelography, in comparison with EID CT myelography, showed higher mean image noise (reader 1: 69.9 ± 18.5 [SD] vs 37.6 ± 15.2; reader 2: 59.5 ± 8.7 vs 49.3 ± 12.7; and reader 3: 57.6 ± 13.2 vs 42.1 ± 16.6), higher mean nerve root sleeve discernibility (reader 1: 81.6 ± 21.7 [SD] vs 30.4 ± 13.6; reader 2: 83.6 ± 10 vs 70.1 ± 18.9; and reader 3: 59.6 ± 13.5 vs 50.5 ± 14.4), and higher mean overall image quality (reader 1: 83.2 ± 20.0 [SD] vs 38.1 ± 13.5; reader 2: 80.1 ± 10.1 vs 72.4 ± 19.8; and reader 3: 57.8 ± 11.2 vs 51.9 ± 13.6) (all p < .05). Eleven patients had a definite CVF. Sensitivity and specificity of EID CT myelography and PCD CT myelography for the detection of definite CVF were 45% and 96% versus 64% and 85%, respectively, for reader 1; 36% and 100% versus 55% and 96%, respectively, for reader 2; and 57% and 100% versus 55% and 93%, respectively, for reader 3. The sensitivity was significantly higher for PCD CT myelography than for EID CT myelography for reader 1 and reader 2 (both p < .05) and was not significantly different between the two techniques for reader 3 (p = .45); for all three readers, specificity was not significantly different between the two modalities (all p > .05). CONCLUSION. In comparison with EID CT myelography, PCD CT myelography yielded significantly improved image quality with significantly higher sensitivity for CVFs (for two of three readers), without significant loss of specificity. CLINICAL IMPACT. The findings support a potential role for PCD CT myelography in facilitating earlier diagnosis and targeted treatment of SIH, avoiding high morbidity during potentially prolonged diagnostic workups.
Collapse
Affiliation(s)
- Fides R Schwartz
- Department of Radiology, Duke University Health System, Durham, NC
| | - Peter G Kranz
- Department of Radiology, Duke University Health System, Durham, NC
| | | | - David N Cox
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Francesco Ria
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Cindy McCabe
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Brian Harrawood
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Linda G Leithe
- Department of Radiology, Duke University Health System, Durham, NC
| | - Ehsan Samei
- Department of Radiology, Duke University Health System, Durham, NC
| | | |
Collapse
|
3
|
Benson JC, Mark IT, Madhavan AA, Johnson-Tesch B, Diehn FE, Carr CM, Kim DK, Brinjikji W, Verdoorn JT. Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks? Neuroradiol J 2024:19714009241242645. [PMID: 38525966 DOI: 10.1177/19714009241242645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH. MATERIALS AND METHODS A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated. RESULTS 174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky). CONCLUSIONS Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.
Collapse
Affiliation(s)
| | - Ian T Mark
- Department of Radiology, Mayo Clinic, USA
| | | | | | | | | | | | | | | |
Collapse
|
4
|
Dillon WP. Spinal Cerebrospinal Fluid Leak Localization with Dynamic Computed Tomography Myelography: Tips, Tricks, and Pitfalls. Radiol Clin North Am 2024; 62:311-319. [PMID: 38272623 DOI: 10.1016/j.rcl.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Locating spinal cerebrospinal fluid (CSF) leaks can be a diagnostic dilemma for clinicians and radiologists, as well as frustrating for patients. Dynamic computed tomography myelography (dCTM) has emerged as a valuable tool in localizing spinal CSF leaks, aiding in accurate diagnosis, and guiding appropriate management. This article aims to provide insights into the technique, tips, tricks, and potential pitfalls associated with dCTM for spinal CSF leak localization. By understanding the nuances of this procedure, clinicians can optimize the diagnostic process and improve patient outcomes.
Collapse
Affiliation(s)
- William P Dillon
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, Room M396A Box 0628, San Francisco, CA 94143-0628, USA.
| |
Collapse
|
5
|
Galvan J, Maya M, Prasad RS, Wadhwa VS, Schievink W. Spinal Cerebrospinal Fluid Leak Localization with Digital Subtraction Myelography: Tips, Tricks, and Pitfalls. Radiol Clin North Am 2024; 62:321-332. [PMID: 38272624 DOI: 10.1016/j.rcl.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Cerebrospinal fluid (CSF) leak can cause spontaneous intracranial hypotension (SIH) which can lead to neurologic symptoms, such as orthostatic headache. Over time, imaging techniques for detecting and localizing CSF leaks have improved. These techniques include computed tomography (CT) myelography, dynamic CT myelography, cone-beam CT, MRI, MR myelography, and digital subtraction myelography (DSM). DSM provides the highest sensitivity for identifying leak sites and has comparable radiation exposure to CT myelography. The introduction of the lateral decubitus DSM has proven invaluable in localizing leaks when other imaging tests have been inconclusive.
Collapse
Affiliation(s)
- Javier Galvan
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Marcel Maya
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048.
| | - Ravi S Prasad
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Vikram S Wadhwa
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Wouter Schievink
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048; Department of Neurosurgery, Cedars-Sinai Medical Center
| |
Collapse
|
6
|
Callen AL, Fakhri M, Timpone VM, Thaker AA, Dillon WP, Shah VN. Temporal Characteristics of CSF-Venous Fistulas on Dynamic Decubitus CT Myelography: A Retrospective Multi-Institution Cohort Study. AJNR Am J Neuroradiol 2023; 45:100-104. [PMID: 38123910 PMCID: PMC10756577 DOI: 10.3174/ajnr.a8078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE CSF-venous fistula can be diagnosed with dynamic decubitus CT myelography. This study aimed to analyze the temporal characteristics of CSF-venous fistula visualization on multiphase decubitus CT myelography. MATERIALS AND METHODS A retrospective, multisite study was conducted on patients diagnosed with CSF-venous fistula at 2 institutions between June 2017 and February 2023. Both institutions perform decubitus CT myelography with imaging immediately following injection and usually with at least 1 delayed scan. The conspicuity of CSF-venous fistula was assessed on each phase of imaging. RESULTS Forty-eight patients with CSF-venous fistula were analyzed. CSF-venous fistulas were better visualized on the early pass in 25/48 cases (52.1%), the delayed pass in 6/48 cases (12.5%) and were seen equally on both passes in 15/48 cases (31.3%). Of 25 cases in which the CSF-venous fistula was better visualized on the early pass, 21/25 (84%) fistulas were still at least partially visible on a delayed pass. Of 6 cases in which the CSF-venous fistula was better visualized on a delayed pass, 4/6 (67%) were partially visible on the earlier pass. Six of 48 (12.5%) CSF-venous fistulas were visible only on a single pass. Of these, 4/6 (66.7%) were seen only on the first pass, and 2/6 (33.3%) were seen only on a delayed pass. One fistula was found with one pass only, and one fistula was discovered upon contralateral decubitus imaging without a dedicated second injection. CONCLUSIONS A dynamic decubitus CT myelography imaging protocol that includes an early and delayed phase, likely increases the sensitivity for CSF-venous fistula detection. Further studies are needed to ascertain the optimal timing and technique for CSF-venous fistula visualization on dynamic decubitus CT myelography and its impact on patient outcomes.
Collapse
Affiliation(s)
- Andrew L Callen
- From the Department of Radiology (A.L.C., V.M.T., A.A.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mo Fakhri
- Department of Radiology and Biomedical Imaging (M.F., W.P.D., V.N.S.), Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - Vincent M Timpone
- From the Department of Radiology (A.L.C., V.M.T., A.A.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ashesh A Thaker
- From the Department of Radiology (A.L.C., V.M.T., A.A.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - William P Dillon
- Department of Radiology and Biomedical Imaging (M.F., W.P.D., V.N.S.), Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - Vinil N Shah
- Department of Radiology and Biomedical Imaging (M.F., W.P.D., V.N.S.), Neuroradiology Section, University of California, San Francisco, San Francisco, California
| |
Collapse
|
7
|
Huynh TJ, Parizadeh D, Ahmed AK, Gandia CT, Davison HC, Murray JV, Mark IT, Madhavan AA, Shlapak D, Rozen TD, Brinjikji W, Vibhute P, Gupta V, Brewer K, Fermo O. Lateral Decubitus Dynamic CT Myelography with Real-Time Bolus Tracking (dCTM-BT) for Evaluation of CSF-Venous Fistulas: Diagnostic Yield Stratified by Brain Imaging Findings. AJNR Am J Neuroradiol 2023; 45:105-112. [PMID: 38164531 PMCID: PMC10756575 DOI: 10.3174/ajnr.a8082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/29/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND PURPOSE CSF-venous fistulas (CVFs) associated with spontaneous intracranial hypotension (SIH) may have a transient appearance, relative to contrast arrival, which may influence the diagnostic performance of lateral decubitus CT myelography (CTM). We developed a dynamic CTM protocol using real-time bolus-tracking (dCTM-BT) to improve the temporal resolution and standardize the timing of CTM acquisitions post-intrathecal contrast administration. The purpose of our study was to evaluate the feasibility of the dCTM-BT technique and evaluate its diagnostic yield for CVF detection, stratified by brain MRI SIH findings. MATERIALS AND METHODS Patients with suspected SIH without extradural fluid collection on spine MRI who underwent dCTM-BT were retrospectively reviewed. CT bolus monitoring was performed at the upper thoracic level. Following the visualization of dense intrathecal contrast, at least 3 CTM acquisitions of the spine were obtained and reviewed by 2 neuroradiologists. The Bern SIH score was calculated on the brain MRI. The diagnostic yield for CVF detection was evaluated, stratified by Bern score categories and a receiver operating characteristic (ROC) analysis. RESULTS Out of 48 patients, 23 (48%) had a CVF on dCTM-BT, located at T1-5 (n = 4), T6-12 (n = 18), L1 (n = 1), with 70% on the right. CVF was identified in 22/22 (100%) of patients who had a high Bern score, 1/7 (14%) of those who had an intermediate score, and 0/19 (0%) of those who had a low score. The area under the ROC curve was 0.99 (95% CI, 0.98-1.00). The optimal cutoff was a Bern score of ≥5 (96% sensitivity, 100% specificity). CONCLUSIONS dCTM-BT is feasible and has excellent diagnostic performance for CVF identification/localization. The Bern score is strongly associated with CVF detection and may help inform who will benefit from dCTM-BT.
Collapse
Affiliation(s)
- Thien J Huynh
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
- Department of Neurosurgery (T.J.H.), Mayo Clinic, Jacksonville, Florida
| | - Donna Parizadeh
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Ahmed K Ahmed
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Christopher T Gandia
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Hal C Davison
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - John V Murray
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Ian T Mark
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Darya Shlapak
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Todd D Rozen
- Department of Neurology (T.D.R., O.F.), Mayo Clinic, Jacksonville, Florida
| | - Waleed Brinjikji
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Prasanna Vibhute
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Vivek Gupta
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Kacie Brewer
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Olga Fermo
- Department of Neurology (T.D.R., O.F.), Mayo Clinic, Jacksonville, Florida
| |
Collapse
|
8
|
Cahal M, Roth J, Ungar OJ, Brinjikji W. Fluctuating hearing loss secondary to spontaneous intracranial hypotension: A case report and review of the literature. Interv Neuroradiol 2023:15910199231221863. [PMID: 38146166 DOI: 10.1177/15910199231221863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE Fluctuating sensorineural hearing loss (SNHL) has multiple etiologies, most commonly Ménière's disease (MD), recurrent sudden SNHL, and autoimmune inner ear disorders. Fluctuating SNHL has rarely been described as a symptom of spontaneous intracranial hypotension (SIH). PATIENT A 39-year-old previously healthy female presented with "Ménière's like" symptoms responsive to steroid treatment, which worsened during the day and improved in the supine position. Conservative treatment for MD consisting of low salt and caffeine diet and betahistine medication yielded no improvement. Secondary revision of brain imaging scans showed signs indicative of SIH, and a spinal cerebrospinal fluid leak was ultimately found and treated by a novel technique of transvenous fistula embolization by means of Onyx® glue, leading to gradual clinical improvement and near-complete resolution of symptoms. CONCLUSION SIH should be considered as part of the differential diagnosis of fluctuating SNHL. Clinical and radiological features should be known and sought. We suspect that early diagnosis and treatment can lead to cure and prevent permanent auditory damage.
Collapse
Affiliation(s)
- Michal Cahal
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | |
Collapse
|
9
|
Lützen N, Demerath T, Würtemberger U, Belachew NF, Barvulsky Aleman E, Wolf K, El Rahal A, Volz F, Fung C, Beck J, Urbach H. Direct comparison of digital subtraction myelography versus CT myelography in lateral decubitus position: evaluation of diagnostic yield for cerebrospinal fluid-venous fistulas. J Neurointerv Surg 2023:jnis-2023-020789. [PMID: 37918908 DOI: 10.1136/jnis-2023-020789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/04/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF)-venous fistulas (CVFs) are increasingly identified as a cause of spontaneous intracranial hypotension (SIH). Lateral decubitus digital subtraction myelography (LD-DSM) and CT myelography (LD-CTM) are mainly used for detection, but the most sensitive method is yet unknown. OBJECTIVE To compare LD-DSM with LD-CTM for diagnostic yield of CVFs. METHODS Patients with SIH diagnosed with a CVF between January 2021 and December 2022 in which the area of CVF(s) was covered by both diagnostic modalities were included. LD-CTM immediately followed LD-DSM without repositioning the spinal needle, and the second half of the contrast agent was injected at the CT scanner. Patients were awake or mildly sedated. Retrospectively, two neuroradiologists evaluated data independently and blinded for the presence of CVF. RESULTS Twenty patients underwent a total of 27 combined LD-DSM/LD-CTM examinations (4/20 with follow-up and 3/20 with bilateral examinations). Both raters identified significantly more CVFs with LD-CTM than with LD-DSM (rater 1: 39 vs 9, P<0.001; rater 2: 42 vs 12, P<0.001). Inter-rater agreement was substantial for LD-DSM (κ=0.732) and LD-CTM (κ=0.655). The results remained significant after considering the senior rating for cases of disagreement (39 vs 10; P<0.001), and no CVF detected on LD-DSM was missed on LD-CTM. CONCLUSION In this study, LD-CTM has a higher diagnostic yield for the detection of CVFs than LD-DSM and should supplement LD-DSM, but further studies are needed. LD-CTM can be easily acquired in awake or mildly sedated patients with the second half of contrast injected just before CT scanning, or it may be considered as a stand-alone investigation.
Collapse
Affiliation(s)
- Niklas Lützen
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Urs Würtemberger
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nebiyat Filate Belachew
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Enrique Barvulsky Aleman
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
10
|
Benson JC, Madhavan AA, Mark IT, Cutsforth-Gregory JK, Brinjikji W, Verdoorn JT. Likelihood of Discovering a CSF Leak Based on Intracranial MRI Findings in Patients without a Spinal Longitudinal Extradural Collection: A New Probabilistic Scoring System. AJNR Am J Neuroradiol 2023; 44:1339-1344. [PMID: 37884301 PMCID: PMC10631522 DOI: 10.3174/ajnr.a8030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/14/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND PURPOSE The likelihood of discovering a CSF leak can be determined by assessing intracranial abnormalities. However, the Dobrocky scoring system, which is used to determine this likelihood, did not incorporate patients with CSF-venous fistulas. This study sought to create a new probabilistic scoring system applicable to patients without a spinal longitudinal extradural collection. MATERIALS AND METHODS A retrospective review was completed of patients with suspected spontaneous intracranial hypotension who underwent brain MR imaging followed by digital subtraction myelography with same-day CT myelography. Patients with and without leaks found on digital subtraction myelography were included. MRIs were assessed for numerous reported stigmata of spontaneous intracranial hypotension and were compared between cohorts. RESULTS One hundred seventy-four patients were included; 113 (64.9%) were women (average age, 52.0 [SD, 14.3] years). A CSF leak was found in 98 (56.3%) patients, nearly all of which (93.9%) were CSF-venous fistulas. Diffuse dural enhancement, internal auditory canals dural enhancement, non-Chiari cerebellar descent, pituitary engorgement, brain sag, dural venous sinus engorgement, and decreased suprasellar cistern size were associated with a CSF leak. A probabilistic scoring system was made in which a single point value was assigned to each of those findings: 0-2 considered low probability and ≥3 considered intermediate-to-high probability of a CSF leak. CONCLUSIONS This study offers a new probabilistic scoring system for evaluating the likelihood of discovering a CSF leak on the basis of intracranial MR imaging findings, though the new system is not superior to that of the Dobrocky method for predicting the presence of CSF leaks.
Collapse
Affiliation(s)
- John C Benson
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ian T Mark
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | | | - Waleed Brinjikji
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Jared T Verdoorn
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
11
|
Callen AL, Jones LC, Timpone VM, Pattee J, Scoffings DJ, Butteriss D, Huynh T, Shen PY, Mamlouk MD. Factors Predictive of Treatment Success in CT-Guided Fibrin Occlusion of CSF-Venous Fistulas: A Multicenter Retrospective Cross-Sectional Study. AJNR Am J Neuroradiol 2023; 44:1332-1338. [PMID: 37798111 PMCID: PMC10631531 DOI: 10.3174/ajnr.a8005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/27/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND PURPOSE CSF-to-venous fistulas contribute to spontaneous intracranial hypotension. CT-guided fibrin occlusion has been described as a minimally invasive treatment strategy; however, its reproducibility across different institutions remains unclear. This multi-institution study evaluated the clinical and radiologic outcomes of CT-guided fibrin occlusion, hypothesizing a correlation among cure rates, fibrin injectate spread, and drainage patterns. MATERIALS AND METHODS A retrospective evaluation was conducted on CT-guided fibrin glue treatment in patients with CSF-to-venous fistulas from 6 US and UK institutions from 2020 to 2023. Patient information, procedural characteristics, and injectate spread and drainage patterns were examined. Clinical improvement assessed through medical records served as the primary outcome. RESULTS Of 119 patients at a mean follow-up of 5.0 months, fibrin occlusion resulted in complete clinical improvement in 59.7%, partial improvement in 34.5%, and no improvement in 5.9% of patients. Complications were reported in 4% of cases. Significant associations were observed between clinical improvement and concordant injectate spread with the fistula drainage pattern (P = .0089) and pretreatment symptom duration (P < .001). No associations were found between clinical improvement and cyst puncture, intravascular extension, rebound headache, body mass index, age, or number of treatment attempts. CONCLUSIONS Fibrin occlusion performed across various institutions shows cure when associated with injectate spread matching the CVF drainage pattern and shorter pretreatment symptom duration, emphasizing the importance of accurate injectate placement and early intervention.
Collapse
Affiliation(s)
- Andrew L Callen
- From the Department of Radiology (A.L.C., V.M.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lalani Carlton Jones
- Imaging Department (L.C.J.), Guys and St Thomas's and Kings College Hospital Foundation Trusts, London, UK
| | - Vincent M Timpone
- From the Department of Radiology (A.L.C., V.M.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jack Pattee
- Department of Biostatistics and Informatics (J.P.), Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, Colorado
| | - Daniel J Scoffings
- Department of Radiology (D.J.S.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - David Butteriss
- Department of Neuroradiology (D.B.), Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - Thien Huynh
- Department of Radiology (T.H.), Division of Neuroradiology, Mayo Clinic, Jacksonville, Florida
| | - Peter Y Shen
- Department of Radiology (P.Y.S., M.D.M.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - Mark D Mamlouk
- Department of Radiology (P.Y.S., M.D.M.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
- Department of Radiology and Biomedical Imaging (M.D.M.), University of California, San Francisco, San Francisco, California
| |
Collapse
|
12
|
Shlapak DP, Mark IT, Kim DK, Benson JC, Diehn FE, Kissoon NR, Liebo GB, Madhavan AA, Morris JM, Morris PP, Oien MP, Verdoorn JT, Carr CM. Incremental diagnostic yield and clinical outcomes of lateral decubitus CT myelogram immediately following negative lateral decubitus digital subtraction myelogram. Neuroradiol J 2023; 36:593-600. [PMID: 37128777 PMCID: PMC10569200 DOI: 10.1177/19714009231173110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
INTRODUCTION Spontaneous intracranial hypotension (SIH) caused by a spinal cerebrospinal fluid (CSF) leak classically presents with orthostatic headache. Digital subtraction myelography (DSM) has a well-established diagnostic yield in the absence of extradural spinal collection. At our institution, DSM is followed by lateral decubitus CT myelogram (LDCTM) in the same decubitus position to increase diagnostic yield of the combined study. We evaluated the incremental diagnostic yield of LDCTM following negative DSM and reviewed patient outcomes. METHODS Retrospective review of consecutive DSMs with subsequent LDCTM from April 2019 to March 2021 was performed. Combined reports were reviewed, and studies with positive DSMs were excluded. Of the exams with negative DSM, only studies with LDCTM reports identifying potential leak site were included. Interventions and follow-up clinical notes were reviewed to assess symptoms improvement following treatment. RESULTS Of the 83 patients with negative DSMs, 11 (13.2%) had positive leak findings on LDCTMs, and 21 (25.3%) were equivocal. Of 11 positive LDCTMs, 6 leaks were nerve sheath tears (NSTs) and 5 were CSF-venous fistulas (CVFs). 10/11 (90.9%) had intervention and follow-up, with 9/10 (90%) having positive clinical outcome. Of the 21 equivocal LDCTM patients (19 CVFs and 2 NSTs), 15 (71.4%) had interventions and follow-up, with 3/15 (20.0%) with positive clinical outcomes. CONCLUSION LDCTM following negative DSM has an incremental diagnostic yield up to 38.6%, with up to 14.5% of positive patient outcomes following treatment. LDCTM should be considered after DSM to maximize diagnostic yield of the combined exam.
Collapse
Affiliation(s)
| | - Ian T Mark
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Narayan R Kissoon
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greta B Liebo
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Michael P Oien
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Carrie M Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
13
|
Madhavan AA, Yu L, Brinjikji W, Cutsforth-Gregory JK, Schwartz FR, Mark IT, Benson JC, Amrhein TJ. Utility of Photon-Counting Detector CT Myelography for the Detection of CSF-Venous Fistulas. AJNR Am J Neuroradiol 2023; 44:740-744. [PMID: 37202116 PMCID: PMC10249691 DOI: 10.3174/ajnr.a7887] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/26/2023] [Indexed: 05/20/2023]
Abstract
CSF-venous fistulas are an increasingly recognized type of CSF leak that can be particularly challenging to detect, even with recently improved imaging techniques. Currently, most institutions use decubitus digital subtraction myelography or dynamic CT myelography to localize CSF-venous fistulas. Photon-counting detector CT is a relatively recent advancement that has many theoretical benefits, including excellent spatial resolution, high temporal resolution, and spectral imaging capabilities. We describe 6 cases of CSF-venous fistulas detected on decubitus photon-counting detector CT myelography. In 5 of these cases, the CSF-venous fistula was previously occult on decubitus digital subtraction myelography or decubitus dynamic CT myelography using an energy-integrating detector system. All 6 cases exemplify the potential benefits of photon-counting detector CT myelography in identifying CSF-venous fistulas. We suggest that further implementation of this imaging technique will likely be valuable to improve the detection of fistulas that might otherwise be missed with currently used techniques.
Collapse
Affiliation(s)
- A A Madhavan
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - L Yu
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - W Brinjikji
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - J K Cutsforth-Gregory
- Department of Radiology and Department of Neurology (J.K.C.-G.), Mayo Clinic, Rochester, Minnesota
| | - F R Schwartz
- Division of Neuroradiology (F.R.S., T.J.A.), Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - I T Mark
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - J C Benson
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - T J Amrhein
- Division of Neuroradiology (F.R.S., T.J.A.), Department of Radiology, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|