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Evangelou P, Omrane MA, Thurow J, Mix M, Fung C, Lützen N, Blazhenets G, Urbach H, Beck J, Meyer PT. 68Ga-DOTA PET for Diagnosis of Spinal Cerebrospinal Fluid Leaks. J Nucl Med 2023; 64:430-436. [PMID: 35981896 DOI: 10.2967/jnumed.122.264059] [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] [Received: 02/23/2022] [Revised: 08/13/2022] [Accepted: 08/13/2022] [Indexed: 11/16/2022] Open
Abstract
Spontaneous intracranial hypotension due to spinal cerebrospinal fluid (CSF) leakage causes substantial disease burden. In many patients, the course is protracted and refractory to conservative treatment, requiring targeted therapy. We propose PET of the CSF space with 68Ga-DOTA as a state-of-the-art approach to radionuclide cisternography (RC) and validate its diagnostic value. Methods: This study is a retrospective analysis of patients with suspected intracranial hypotension due to spinal CSF leaks and who underwent whole-body PET/CT at 1, 3, and 5 h after intrathecal lumbar injection of 68Ga-DOTA. Two independent raters unaware of the clinical data analyzed all scans for direct and indirect RC signs of CSF leakage. Volume-of-interest analysis was performed to assess the biologic half-life of the tracer in the CSF space and the ratio of decay-corrected activity in the CSF space at 5 and 3 h (simplified marker of tracer clearance). Comprehensive stepwise neuroradiologic work-up served as a reference; additional validation was provided by surgical findings and follow-up. Results: Of 40 consecutive patients, 39 patients with a working diagnosis of intracranial hypotension due to a spinal CSF leak (spontaneous, n = 31; postintervention, n = 8) could be analyzed. A spinal CSF leak was verified by the neuroradiologic reference method in 18 of 39 patients. As the only direct and indirect diagnostic signs, extrathecal tracer accumulation at the cervicothoracic junction (67% sensitivity and 90% specificity) and lack of activity over the cerebral convexities (5 h; 94% sensitivity and 67% specificity) revealed a high diagnostic value for spinal CSF leaks. Their combination provided little improvement (71% sensitivity and 95% specificity). Additional quantitative analyses yielded no benefit (94% sensitivity and 53% specificity for biological half-life; 94% sensitivity and 58% specificity for the ratio of total radioactivity within the CSF space at 5 and 3 h). The location of direct signs (extrathecal tracer accumulation) did not correlate with verified sites of spinal CSF leakage. Conclusion: We propose CSF PET with 68Ga-DOTA as a novel, fast, and convenient approach to RC for verification but not localization of spinal CSF leaks with high sensitivity and specificity. CSF PET may fulfill an important gatekeeper function for stratifying patients toward escalation (ruling in) or deescalation (ruling out) of diagnostic and therapeutic measures. Further prospective studies are needed to validate the present results and determine the potential of the methods to reduce the burden to patients.
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Affiliation(s)
- Petros Evangelou
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mohamed Aymen Omrane
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Johannes Thurow
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Michael Mix
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Christian Fung
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ganna Blazhenets
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp T Meyer
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
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Porubcin S, Rovnakova A, Zahornacky O, Jarcuska P. Diagnostic Value of Radioisotope Cisternography Using 111In-DTPA in a Patient with Rhinorrhea and Purulent Meningitis. Medicina (B Aires) 2022; 58:medicina58060714. [PMID: 35743977 PMCID: PMC9229997 DOI: 10.3390/medicina58060714] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022] Open
Abstract
Cerebrospinal fluid (CSF) leakage is a rare condition. Prompt diagnosis and early treatment of CSF leakage minimizes the risk of severe complications such as bacterial meningitis. Different diagnostic modalities are used to detect the site of CSF leakage but often with unreliable results. The literature offers limited evidence-based guidance on the diagnostic approach for rhinorrhea. Correct localization of the defect is the mainstay for successful surgical treatment. Herein, we describe a case of recurrent meningitis due to cranio-nasal fistula and rhinorrhea successfully localized with radioisotope cisternography (RIC). We provide a detailed and practical overview of the RIC procedure and compare different imaging modalities used to detect the site of CSF leakage.
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Affiliation(s)
- Stefan Porubcin
- The Department of Infectious Diseases and Travel Medicine, Louis Pasteur University Hospital, Rastislavova 43, 04011 Kosice, Slovakia; (S.P.); (A.R.)
- Faculty of Medicine, Pavol Jozef Safarik University in Kosice, Trieda SNP No. 1, 04011 Kosice, Slovakia
| | - Alena Rovnakova
- The Department of Infectious Diseases and Travel Medicine, Louis Pasteur University Hospital, Rastislavova 43, 04011 Kosice, Slovakia; (S.P.); (A.R.)
| | - Ondrej Zahornacky
- The Department of Infectious Diseases and Travel Medicine, Louis Pasteur University Hospital, Rastislavova 43, 04011 Kosice, Slovakia; (S.P.); (A.R.)
- Faculty of Medicine, Pavol Jozef Safarik University in Kosice, Trieda SNP No. 1, 04011 Kosice, Slovakia
- Correspondence: (O.Z.); (P.J.)
| | - Pavol Jarcuska
- The Department of Infectious Diseases and Travel Medicine, Louis Pasteur University Hospital, Rastislavova 43, 04011 Kosice, Slovakia; (S.P.); (A.R.)
- Faculty of Medicine, Pavol Jozef Safarik University in Kosice, Trieda SNP No. 1, 04011 Kosice, Slovakia
- Correspondence: (O.Z.); (P.J.)
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