1
|
Callen AL, Friedman DI, Parikh S, Rau JC, Schievink WI, Cutsforth-Gregory JK, Amrhein TJ, Haight E, Cowan RP, Barad MJ, Hah JM, Jackson T, Deline C, Buchanan AJ, Carroll I. Diagnosis and Treatment of Spontaneous Intracranial Hypotension: Role of Epidural Blood Patching. Neurol Clin Pract 2024; 14:e200290. [PMID: 38699599 PMCID: PMC11065326 DOI: 10.1212/cpj.0000000000200290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/23/2024] [Indexed: 05/05/2024]
Abstract
Purpose of Review This review focuses on the challenges of diagnosing and treating spontaneous intracranial hypotension (SIH), a condition caused by spinal CSF leakage. It emphasizes the need for increased awareness and advocates for early and thoughtful use of empirical epidural blood patches (EBPs) in suspected cases. Recent Findings SIH diagnosis is hindered by variable symptoms and inconsistent imaging results, including normal brain MRI and unreliable spinal opening pressures. It is crucial to consider SIH in differential diagnoses, especially in patients with connective tissue disorders. Early EBP intervention is shown to improve outcomes. Summary SIH remains underdiagnosed and undertreated, requiring heightened awareness and understanding. This review promotes proactive EBP use in managing suspected SIH and calls for continued research to advance diagnostic and treatment methods, emphasizing the need for innovative imaging techniques for accurate diagnosis and timely intervention.
Collapse
Affiliation(s)
- Andrew L Callen
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Deborah I Friedman
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Simy Parikh
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Jill C Rau
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Wouter I Schievink
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Jeremy K Cutsforth-Gregory
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Timothy J Amrhein
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Elena Haight
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Robert P Cowan
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Meredith J Barad
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Jennifer M Hah
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Tracy Jackson
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Connie Deline
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Andrea J Buchanan
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| | - Ian Carroll
- Department of Radiology (ALC), University of Colorado Anschutz Medical Campus, Denver; Yellow Rose Headache and Neurology-Ophthalmology (DIF), Dallas, TX; Department of Neurology (SP), Thomas Jefferson University, Philadelphia, PA; Bob Bove Neuroscience Institute (JCR), HonorHealth Neurology, Scottsdale, AZ; Department of Neurosurgery (WIS), Cedars Sinai Medical Center, Beverly Hills, CA; Department of Neurology (JKC-G), Mayo Clinic, Rochester, MN; Department of Radiology (TJA), Duke University, Durham, NC; Department of Anesthesia (EH), UCSF, San Francisco, CA; Departments of Neurology (RPC, MJB) and Anesthesiology (JMH, IC), Stanford University, Stanford, CA; Opos Solutions (TJ), San Mateo, CA; and Spinal CSF Leak Foundation (CD, AJB), Spokane, WA
| |
Collapse
|
2
|
Cagnazzo F, Ducros A, Risi G, Charif M, Corti L, Rapido F, Le Bars E, Lonjon N, Costalat V. Safety and efficacy of transvenous embolization of cerebrospinal fluid-venous fistula in patients with spontaneous intracranial hypotension. Interv Neuroradiol 2024:15910199241247698. [PMID: 38651327 DOI: 10.1177/15910199241247698] [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: 04/25/2024] Open
Abstract
BACKGROUND Transvenous embolization is a recent treatment strategy for cerebrospinal fluid-venous fistulas (CSFVF), which are associated with spontaneous intracranial hypotension (SIH). METHODS Participants were selected from a prospective database on patients with CSFVF that received transvenous Onyx embolization. All patients underwent a brain magnetic resonance imaging (MRI) before and after embolization with MRI follow-up performed at least 3 months after treatment. Clinical and MRI results after treatment were described. RESULTS Twenty-one consecutive patients (median age 63 years, IQR = 58-71; females: 15/21 = 71.5%) with 30 CSFVF were included. Most lesions were situated between T9 and L1 (19/30 = 63%), 70% were right-sided, and 38% of the patients had multiples fistulas. Embolization was successful in all cases. The mean MRI SIH score before and after treatment was 6 (±2.5) and 1.4 (±1.6), respectively (p < 0.0001). Twenty patients (90%) experienced improvement of their initial condition, of which 67% reported complete clinical recovery. The mean HIT-6 score decreased from 67 (±15) to 38 (±9) (p < 0.0001), the mean amount of monthly headache days from 23.5 (±10) and 3.2 (±6.6) (p < 0.0001), the visual assessment scale (VAS) for headache severity from 8 (±1.9) to 1.2 (±2) (p < 0.0001), and the mean VAS for perception quality of life improved from 2.6 (±2.5) to 8.6 (±1.8) (p < 0.0001). There were no major complications. The suspected rebound headache rate after treatment was 33%. CONCLUSION Transvenous embolization of CSFVF allowed high rates of clinical improvement with no morbidity related to the treatment.
Collapse
Affiliation(s)
- Federico Cagnazzo
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Anne Ducros
- Neurorology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Gaetano Risi
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Mahmoud Charif
- Neurorology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Lucas Corti
- Neurorology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Francesca Rapido
- Anesthesiology and Critical Care Medicine, Montpellier University Hospital, Gui de Chauliac Montpellier, France
| | - Emmanuelle Le Bars
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Nicolas Lonjon
- Anesthesiology and Critical Care Medicine, Montpellier University Hospital, Gui de Chauliac Montpellier, France
| | - Vincent Costalat
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| |
Collapse
|
3
|
Peters DR, Bernard J, Morgan R, Rossi V. Posterior Transdural Repair of a Spontaneous Ventral Thoracic Cerebrospinal Fluid Leak: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01127. [PMID: 38634675 DOI: 10.1227/ons.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/19/2024] [Indexed: 04/19/2024] Open
Abstract
Spontaneous intracranial hypotension is a rare but serious condition characterized by orthostatic headaches and a variety of neurological symptoms. 1,2 Spontaneous intracranial hypotension should be considered in all patients with new onset, daily, persistent headaches, and orthostatic symptoms. It is typically caused by spontaneous spinal cerebrospinal fluid (CSF) leaks. 1,2 Traditional first-line treatments include hydration, bedrest, epidural blood patches, and fibrin glue injections. However, refractory cases often require surgical intervention, especially those caused by a small ventral osteophyte, which is classified as a type 1 leak. 3-5 The small osteophyte causes a tear in the dura of the ventral canal, usually near the cervicothoracic junction. Diagnosis of these leaks is challenging because these small osteophytes can also occur asymptomatically, or patients may have several of them at multiple levels. Typically, dynamic myelography is needed for accurate localization due to the inadequacy of standard imaging. 6 This video details a young patient with refractory spontaneous intracranial hypotension from a type 1 spontaneous CSF leak, treated successfully using a posterior transdural surgical approach with spinal cord mobilization. Our video presentation outlines the surgical technique and provides an overview of this underdiagnosed condition. Our described approach offers direct visualization, suturing of the leak site, and a multilayer repair without the need for spinal fusion. It also avoids the morbidity to the neck, chest, and mediastinal structures that is at risk with lateral or anterior approaches. A combined intradural and extradural repair may enhance the durability of repair for ventral CSF leaks. The patient consented to the procedure. This operative video did not require Institutional Review Board approval as all patient information has been anonymized, ensuring no identifiable information is disclosed. The video is a single case that does not involve interventions or pose risks beyond standard care, adhering to ethical guidelines and institutional policies.
Collapse
Affiliation(s)
- David R Peters
- Carolina Neurosurgery and Spine Associates, Charlotte , North Carolina , USA
- Department of Neurosurgery, Atrium Health, Charlotte , North Carolina , USA
| | - Joe Bernard
- Carolina Neurosurgery and Spine Associates, Charlotte , North Carolina , USA
- Department of Neurosurgery, Atrium Health, Charlotte , North Carolina , USA
| | - Robert Morgan
- Charlotte Radiology, Charlotte , North Carolina , USA
| | - Vincent Rossi
- Carolina Neurosurgery and Spine Associates, Charlotte , North Carolina , USA
- Department of Neurosurgery, Atrium Health, Charlotte , North Carolina , USA
| |
Collapse
|
4
|
Faghani S, Moassefi M, Madhavan AA, Mark IT, Verdoorn JT, Erickson BJ, Benson JC. Identifying Patients with CSF-Venous Fistula Using Brain MRI: A Deep Learning Approach. AJNR Am J Neuroradiol 2024; 45:439-443. [PMID: 38423747 DOI: 10.3174/ajnr.a8173] [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: 09/27/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension is an increasingly recognized condition. Spontaneous intracranial hypotension is caused by a CSF leak, which is commonly related to a CSF-venous fistula. In patients with spontaneous intracranial hypotension, multiple intracranial abnormalities can be observed on brain MR imaging, including dural enhancement, "brain sag," and pituitary engorgement. This study seeks to create a deep learning model for the accurate diagnosis of CSF-venous fistulas via brain MR imaging. MATERIALS AND METHODS A review of patients with clinically suspected spontaneous intracranial hypotension who underwent digital subtraction myelogram imaging preceded by brain MR imaging was performed. The patients were categorized as having a definite CSF-venous fistula, no fistula, or indeterminate findings on a digital subtraction myelogram. The data set was split into 5 folds at the patient level and stratified by label. A 5-fold cross-validation was then used to evaluate the reliability of the model. The predictive value of the model to identify patients with a CSF leak was assessed by using the area under the receiver operating characteristic curve for each validation fold. RESULTS There were 129 patients were included in this study. The median age was 54 years, and 66 (51.2%) had a CSF-venous fistula. In discriminating between positive and negative cases for CSF-venous fistulas, the classifier demonstrated an average area under the receiver operating characteristic curve of 0.8668 with a standard deviation of 0.0254 across the folds. CONCLUSIONS This study developed a deep learning model that can predict the presence of a spinal CSF-venous fistula based on brain MR imaging in patients with suspected spontaneous intracranial hypotension. However, further model refinement and external validation are necessary before clinical adoption. This research highlights the substantial potential of deep learning in diagnosing CSF-venous fistulas by using brain MR imaging.
Collapse
Affiliation(s)
- Shahriar Faghani
- From the Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Mana Moassefi
- From the Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Ian T Mark
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Bradley J Erickson
- From the Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
5
|
Frič R, Heier I, Züchner M, Gjertsen Ø, Rezai M. Cerebrospinal fluid-lymphatic fistula in a child with generalized lymphatic anomaly treated with targeted blood patch - a rare case report and review of the literature. Childs Nerv Syst 2024; 40:1301-1305. [PMID: 38236406 PMCID: PMC10973078 DOI: 10.1007/s00381-024-06287-x] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
Spontaneous intracranial hypotension may result in debilitating postural headaches and severe neurological symptoms due to secondary cerebellar sagging. The most common cause is the cerebrospinal fluid (CSF) leak within the spinal canal. Although previously reported in only a few cases, also paraspinal lymphatic malformations causing vertebral bone destruction may occasionally result in CSF leak to these pathological formations. Here, we present a case of a 9-year-old girl with generalized lymphatic anomaly (GLA) presenting with severe postural headache. Radiological imaging revealed a typical feature of cerebellar sagging. Myelography localized the CSF leakage into vertebral bodies of C7 and Th1, which both were partly involved in pathological paravertebral masses of known lymphatic anomaly, and from there along the right C8 nerve root sleeve into the anomaly. As the C8-nerve root could not be ligated due to the risk of significant neurological injury, we attempted image-guided targeted percutaneous epidural placement of a blood patch directly into the foramen at the affected level. The procedure resulted in obliteration of the fistula and regression of cerebellar sagging, with significant relief of symptoms. Although it is an extremely rare coincidence, patients with paraspinal lymphatic malformations may develop intraspinal CSF leak into these pathological formations. The present case report suggests that besides a direct surgical obliteration of the fistula and sacrificing the nerve root, a targeted percutaneous epidural blood patch may be a possible alternative in the case of a functionally important nerve root.
Collapse
Affiliation(s)
- Radek Frič
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O.Box 4950, N-0424, Oslo, Norway.
| | - Ingvild Heier
- Department of Pediatric Hematology and Oncology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Mark Züchner
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O.Box 4950, N-0424, Oslo, Norway
| | - Øivind Gjertsen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Mehran Rezai
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
6
|
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
|
7
|
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
|
8
|
Orscelik A, Cutsforth-Gregory JK, Madhavan A, Senol YC, Kobeissi H, Belge Bilgin G, Bilgin C, Kallmes DF, Brinjikji W. Endovascular Embolization Techniques for Cerebrospinal Fluid-Venous Fistula in the Treatment of Spontaneous Intracranial Hypotension. Radiol Clin North Am 2024; 62:345-354. [PMID: 38272626 DOI: 10.1016/j.rcl.2023.10.006] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Cerebrospinal fluid-venous fistula (CVF) is an important cause of spontaneous intracranial hypotension (SIH), a condition characterized by low cerebrospinal fluid (CSF) volume and orthostatic headaches. The pathogenesis of CVF is thought to be direct connection of the spinal dura to one or more veins in the epidural space, allowing unregulated flow of CSF into the venous system. Herein, we provide a comprehensive review of the endovascular management of CVF in patients with SIH. We also focus on the various techniques and devices used in endovascular treatment, as well as the pathogenesis, diagnosis, and alternative treatment options of CVF.
Collapse
Affiliation(s)
| | | | - Ajay Madhavan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Yigit Can Senol
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
9
|
Carlton Jones L, Hoffmann J, Mohideen S, Stanton B, Bleil C, Britton T, Goadsby PJ, Zebian B. Management of cervical CSF-venous fistula causing acute cognitive impairment and coma. Acta Neurochir (Wien) 2024; 166:37. [PMID: 38277029 DOI: 10.1007/s00701-024-05935-0] [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: 07/03/2023] [Accepted: 12/03/2023] [Indexed: 01/27/2024]
Abstract
CSF-venous fistulas (CVFs) are increasingly recognised as a cause of spontaneous intracranial hypotension. They may present atypically including with brain sagging pseudo-dementia. Cervical CVFs are rare and their management can be difficult due to associated eloquent nerve roots. We report the case of a 49-year-old woman who presented with cognitive decline progressing to coma. Brain imaging showed features of spontaneous intracranial hypotension and a right C7 CVF was identified at digital subtraction and CT myelography. Initial treatment with CT-guided injection of fibrin sealant produced temporary improvement in symptoms before surgical treatment resulted in total clinical remission and radiological resolution.
Collapse
Affiliation(s)
- Lalani Carlton Jones
- Department of Neuroradiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
- Department of Radiology, Guy's and St Thomas' Hospitals NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Rd, London, SE1 7EH, UK.
| | - Jan Hoffmann
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Saamir Mohideen
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Biba Stanton
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Cristina Bleil
- Department of Neurosurgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Tom Britton
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Peter J Goadsby
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Bassel Zebian
- Department of Neurosurgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| |
Collapse
|
10
|
Cordeiro de Macedo Pontes Í, Leão Edelmuth DG, Takahara S, Noda Kihara Filho E, Lucato LT, Partezani Helito PV, Kranz PG. CT Myelography: How to Do It. Radiographics 2024; 44:e230088. [PMID: 38096111 DOI: 10.1148/rg.230088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Írline Cordeiro de Macedo Pontes
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Diogo Guilherme Leão Edelmuth
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Stephanie Takahara
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Eduardo Noda Kihara Filho
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Leandro Tavares Lucato
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Paulo Victor Partezani Helito
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Peter G Kranz
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| |
Collapse
|
11
|
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
|
12
|
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
|
13
|
Ellens NR, Schartz D, Ismail R, Kessler A, Ellika S, Akkipeddi SMK, Rahmani R, Bender MT. Efficacy of transvenous embolization of CSF-venous fistula in spontaneous intracranial hypotension: Case-series. Interv Neuroradiol 2023:15910199231221449. [PMID: 38130106 DOI: 10.1177/15910199231221449] [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: 12/23/2023] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension is a debilitating neurological condition which can be caused by a cerebrospinal fluid-venous fistula. Transvenous embolization is a promising technique to provide minimally invasive yet durable treatment. METHODS A retrospective single-center case series was performed on all patients who underwent transvenous embolization of a cerebrospinal fluid (CSF)-venous fistula. Clinical and radiographic parameters, including Bern score, were reported preoperatively and at 3-month follow-up. RESULTS Six patients underwent embolization of a CSF-venous fistula. All fistulae were located in the thoracic spine and technical success was achieved in all cases. Three patients had symptom resolution, two had significant improvement, and one had stable symptoms on follow-up. The mean Bern score was 6.83 (SD = 1.47) preoperatively and 1.83 (SD = 1.64) postoperatively with a mean improvement in Bern score of 5.0 (SD = 1.9, p = 0.0013). CONCLUSIONS CSF-venous fistulas are an increasingly recognized clinical entity which may be treated with transvenous embolization. This case series serves to further validate this technique and suggests it can be performed with similar outcomes in lower volume centers.
Collapse
Affiliation(s)
- Nathaniel R Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Shehenaz Ellika
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
14
|
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
|
15
|
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
|
16
|
Brinjikji W, Madhavan A, Garza I, Whealy M, Kissoon N, Mark I, Morris PP, Verdoorn J, Benson J, Atkinson JLD, Kobeissi H, Cutsforth-Gregory JK. Clinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization. J Neurointerv Surg 2023:jnis-2023-021012. [PMID: 37898553 DOI: 10.1136/jnis-2023-021012] [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: 09/08/2023] [Accepted: 10/14/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Cerebrospinal fluid-venous fistulas (CSFVF) are a common cause of spontaneous intracranial hypotension (SIH). Transvenous embolization has emerged as a reliable treatment option. We review the clinical presentation, imaging, and clinical outcomes of 100 consecutive CSFVF patients who underwent embolization over 2 years. METHODS Baseline clinical characteristics, imaging findings (including Bern SIH score), technical outcomes, and long-term imaging and clinical outcomes were collected. All patients had at least 3 months of clinical follow-up and had baseline MRI. 99/100 patients underwent follow-up imaging at ≥3 months post-treatment. RESULTS 100 patients were included. Mean imaging and clinical follow-up duration was 8.3±7.7 months and 15.0±6.8 months, respectively. The mean duration of symptoms before embolization was 40.9±52 months. Mean baseline Bern SIH score was 5.9±3.3. The most common baseline symptoms were headache (96 patients), tinnitus (55 patients), and cognitive dysfunction (44 patients). Technical success rate was 100%. Mean post-treatment Bern SIH score was 0.9±1.6 (P<0.0001). Following treatment, 95% of patients reported significant improvement or resolution in symptoms (58 patients reporting resolution and 37 reporting improvement). 5 patients reported no improvement. There were no major procedural or periprocedural complications. 10 patients had minor procedural complications that did not result in any change in management (Onyx emboli, venous perforation). 19 patients had rebound intracranial hypertension requiring acetazolamide therapy. 7 patients had recurrent fistula at the initially treated level. CONCLUSIONS Transvenous embolization of CSFVF in SIH patients is safe and effective with a 95% treatment response, significant improvement in imaging outcomes, and a very low rate of complications.
Collapse
Affiliation(s)
- Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ajay Madhavan
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ivan Garza
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Whealy
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Narayan Kissoon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian Mark
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pearse P Morris
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jared Verdoorn
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John L D Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | |
Collapse
|
17
|
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
|
18
|
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
|
19
|
Farb RI, O'Reilly ST, Hendriks EJ, Peng PW, Massicotte EM, Hoydonckx Y, Nicholson PJ. Spontaneous intracranial hypotension due to CSF-venous fistula: Evaluation of renal accumulation of contrast following decubitus myelography and maintained decubitus CT to improve fistula localization. Interv Neuroradiol 2023:15910199231172627. [PMID: 37211661 DOI: 10.1177/15910199231172627] [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: 05/23/2023] Open
Abstract
PURPOSE Presented here is a strategy of sequential lateral decubitus digital subtraction myelography (LDDSM) followed closely by lateral decubitus CT (LDCT) to facilitate cerebrospinal fluid (CSF)-venous fistula (CVF) localization. MATERIALS AND METHODS This is a retrospective analysis of patients referred to our institution for evaluation of CSF leak. Patients with Type 1 and Type 2 leaks, and those not displaying MR brain stigmata of intracranial hypotension were excluded. All patients underwent consecutive LDDSM and LDCT. If the CVF was not localized on the first LDDSM-LDCT pair the patient returned for contralateral examinations. Images were reviewed for CVF and for accumulation of contrast within the renal pelvises expressed as a renal pelvis contrast score (RPCS) in Hounsfield units (HU). RESULTS Twenty-two patients were included in this study. In 21 of 22 patients (95%) a CVF was identified yielding an RPCS for the LDDSM-LDCT pair ipsilateral to the CVF ranging from 71 to 423 with an average of 146 HU. An RPCS of the negative side LDDSM-LDCT pair contralateral to a CVF was available in 8 patients and averaged 51 HU. In 4 patients the initial bilateral LDDSM-LDCT pairs did not reveal the location of the CVF however in 3 of these 4 cases the CVF was revealed on a third LDDSM repeated ipsilateral to the higher RPCS. CONCLUSION The strategy of sequential LDDSM-LDCT coupled with evaluation of renal accumulation of contrast agent appears to improve the rate of CVF localization and warrants further evaluation.
Collapse
Affiliation(s)
- Richard I Farb
- Department of Diagnostic Imaging, Division of Neuroradiology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sean T O'Reilly
- Department of Diagnostic Imaging, Division of Neuroradiology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Everardus J Hendriks
- Department of Diagnostic Imaging, Division of Neuroradiology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philip W Peng
- Department of Anesthesiology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric M Massicotte
- Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yasmine Hoydonckx
- Department of Anesthesiology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Patrick J Nicholson
- Department of Diagnostic Imaging, Division of Neuroradiology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
20
|
Wagle S, Benson JC, Madhavan AA, Carr CM, Garza I, Diehn FE, Kim DK. The clue is in the kidneys: greater renal contrast medium accumulation on ipsilateral side down CT myelogram after lateral decubitus digital subtraction myelogram as a predictor of laterality of cerebrospinal fluid leak. Clin Radiol 2023:S0009-9260(23)00173-3. [PMID: 37225571 DOI: 10.1016/j.crad.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 03/31/2023] [Accepted: 04/23/2023] [Indexed: 05/26/2023]
Abstract
AIM To assess the potential correlation of the laterality of a cerebrospinal fluid (CSF)-venous fistula with the laterality of decubitus computed tomography (CT) myelogram (post decubitus digital subtraction myelogram) based on which side demonstrated more renal contrast medium excretion. MATERIALS AND METHODS Patients with CSF-venous fistulas diagnosed at lateral decubitus digital subtraction myelograms were reviewed retrospectively. Patients who did not have CT myelogram following one or both left and right lateral decubitus digital subtraction myelograms were excluded. Two neuroradiologists independently interpreted the CT myelogram for the presence or absence of renal contrast, and whether subjectively more renal contrast medium was visualised on the left or right lateral decubitus CT myelogram. RESULTS Renal contrast medium was seen in lateral decubitus CT myelograms in 28 of 30 (93.3%) patients with CSF-venous fistulas. Having more renal contrast medium in right lateral decubitus CT myelogram was 73.9% sensitive and 71.4% specific for the diagnosis of a right-sided CSF-venous fistula, whereas having more renal contrast medium in the left lateral decubitus CT myelogram was 71.4% sensitive and 82.6% specific for a left-sided CSF-venous fistula (p=0.02). CONCLUSION When the CSF-venous fistula lies on the dependent side of a decubitus CT myelogram performed after decubitus digital subtraction myelogram, relatively more renal contrast medium is visualised compared to when the fistula lies on the non-dependent side.
Collapse
Affiliation(s)
- S Wagle
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - J C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| | - A A Madhavan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - C M Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - I Garza
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - F E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - D K Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
21
|
Mark I, Madhavan A, Oien M, Verdoorn J, Benson JC, Cutsforth-Gregory J, Brinjikji W, Morris P. Temporal Characteristics of CSF-Venous Fistulas on Digital Subtraction Myelography. AJNR Am J Neuroradiol 2023; 44:492-495. [PMID: 36894299 PMCID: PMC10084909 DOI: 10.3174/ajnr.a7809] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [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: 11/15/2022] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND PURPOSE CSF-venous fistula can be diagnosed with multiple myelographic techniques; however, no prior work has characterized the time to contrast opacification and the duration of visualization. The purpose of our study was to evaluate the temporal characteristics of CSF-venous fistula on digital subtraction myelography. MATERIALS AND METHODS We reviewed the digital subtraction myelography images of 26 patients with CSF-venous fistulas. We evaluated how long the CSF-venous fistula took to opacify after contrast reached the spinal level of interest and how long it remained opacified. Patient demographics, CSF-venous fistula treatment, brain MR imaging findings, CSF-venous fistula spinal level, and CSF-venous fistula laterality were recorded. RESULTS Eight of the 26 CSF-venous fistulas were seen on both the upper- and lower-FOV digital subtraction myelography, for a total of 34 CSF-venous fistula views evaluated on digital subtraction myelography. The mean time to appearance was 9.1 seconds (range, 0-30 seconds). Twenty-two (84.6%) of the CSF-venous fistulas were on the right. The highest fistula level was C7, while the lowest was T13 (13 rib-bearing vertebral bodies). The most common CSF-venous fistula levels were T6 (4 patients) followed by T8, T10, and T11 (3 patients each). The mean age was 58.3 years (range, 31.7-87.6 years). Sixteen patients were women (61.5%). CONCLUSIONS This is the first study to report the temporal characteristics of CSF-venous fistulas using digital subtraction myelography. We found that on average, the CSF-venous fistula appeared 9.1 seconds (range, 0-30 seconds) after intrathecal contrast reached the spinal level.
Collapse
Affiliation(s)
- I Mark
- From the Departments of Radiology (I.M., A.M., M.O., J.V., J.C.B., W.B., P.M.)
| | - A Madhavan
- From the Departments of Radiology (I.M., A.M., M.O., J.V., J.C.B., W.B., P.M.)
| | - M Oien
- From the Departments of Radiology (I.M., A.M., M.O., J.V., J.C.B., W.B., P.M.)
| | - J Verdoorn
- From the Departments of Radiology (I.M., A.M., M.O., J.V., J.C.B., W.B., P.M.)
| | - J C Benson
- From the Departments of Radiology (I.M., A.M., M.O., J.V., J.C.B., W.B., P.M.)
| | | | - W Brinjikji
- From the Departments of Radiology (I.M., A.M., M.O., J.V., J.C.B., W.B., P.M.)
| | - P Morris
- From the Departments of Radiology (I.M., A.M., M.O., J.V., J.C.B., W.B., P.M.)
| |
Collapse
|
22
|
Madhavan AA, Cutsforth-Gregory JK, Benson JC, Brinjikji W, Mark IT, Verdoorn JT. Conebeam CT as an Adjunct to Digital Subtraction Myelography for Detection of CSF-Venous Fistulas. AJNR Am J Neuroradiol 2023; 44:347-350. [PMID: 36759140 PMCID: PMC10187817 DOI: 10.3174/ajnr.a7794] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/05/2022] [Accepted: 01/13/2023] [Indexed: 02/11/2023]
Abstract
Lateral decubitus digital subtraction myelography is an effective technique for precisely localizing CSF-venous fistulas, a common cause of spontaneous intracranial hypotension. However, despite an optimal imaging technique, digital subtraction myelography fails to identify some CSF-venous fistulas for a variety of reasons. Here, we describe a technique involving conebeam CT performed during intrathecal contrast injection as an adjunct to digital subtraction myelography, allowing identification of some otherwise-missed CSF-venous fistulas.
Collapse
Affiliation(s)
- A A Madhavan
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - J K Cutsforth-Gregory
- Department of Radiology and Department of Neurology (J.K.C.-G.), Mayo Clinic, Rochester, Minnesota
| | - J C Benson
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - W Brinjikji
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - I T Mark
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - J T Verdoorn
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| |
Collapse
|
23
|
Sobański D, Staszkiewicz R, Stachura M, Gadzieliński M, Grabarek BO. Presentation, Diagnosis, and Management of Lower Back Pain Associated with Spinal Stenosis: A Narrative Review. Med Sci Monit 2023; 29:e939237. [PMID: 36814366 PMCID: PMC9972697 DOI: 10.12659/msm.939237] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Lower back pain (LBP) is an extremely common symptom experienced by people of all ages and is also one of the most frequent causes of disability worldwide. This article aims to review the presentation, diagnosis, and management of lower back pain associated with spinal stenosis. The paper we prepared was classified as a "literature narrative review." Nonetheless, when searching for manuscripts included in our work and reviewing them critically, we concentrated on the keywords: "lower back pain", "lumbar spine stenosis", "diagnostic", "rehabilitation", "neurosurgery", "spine", and "elderly". The incidence of chronic lower back pain (CLBP) increases linearly starting with the third decade of life until 60 years old, and it more often affects women. The course of non-specific LBP above all depends on factors not connected with the spine, which include psychological, behavioral, and social factors, determined by the way the condition is perceived by the patient the environment. Lumbar spine stenosis (LSS) is an age-related process of degeneration of the intervertebral discs, ligamentum flavum, and facet joints, which results in narrowing of the space around the neurovascular structures of the spine. Diagnosis of spinal pain syndromes includes radiography (RTG), computed tomography (CT), and magnetic resonance imaging (MRI). Based on the results of imaging studies, neurological examination, and the severity of the disease, treatment can consist of analgesics and rehabilitation, or, when conservative methods are insufficient, surgical treatment is indicated.
Collapse
Affiliation(s)
- Dawid Sobański
- Department of Histology, Cytophysiology and Embryology, Academy of Silesia, Katowice, Poland,Department of Neurosurgery, Szpital sw. Rafała in Cracow, Cracow, Poland
| | - Rafał Staszkiewicz
- Department of Histology, Cytophysiology and Embryology, Academy of Silesia, Katowice, Poland,Department of Neurosurgery, 5 Military Clinical Hospital with the SP ZOZ Polyclinic in Cracow, Cracow, Poland
| | - Magdalena Stachura
- Department of Neurosurgery, Szpital sw. Rafała in Cracow, Cracow, Poland,Department of Children’s Neurosurgery, Jagiellonian University Medical College, Cracow, Poland
| | - Marcin Gadzieliński
- Department of Neurosurgery, 5 Military Clinical Hospital with the SP ZOZ Polyclinic in Cracow, Cracow, Poland
| | - Beniamin Oskar Grabarek
- Department of Histology, Cytophysiology and Embryology, Academy of Silesia, Katowice, Poland,Department of Neurosurgery, 5 Military Clinical Hospital with the SP ZOZ Polyclinic in Cracow, Cracow, Poland
| |
Collapse
|
24
|
Konovalov AN, Grebenev FV, Asyutin DS, Zakirov BA, Konovalov NA, Pronin IN, Eliava SS. [Spontaneous dural CSF fistula as a cause of intracranial hypotension syndrome. Case report and literature review]. Zh Vopr Neirokhir Im N N Burdenko 2023; 87:63-70. [PMID: 37011330 DOI: 10.17116/neiro20238702163] [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] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Typical symptoms of spontaneous intracranial hypotension syndrome are severe headache, weakness, dizziness and inability to stay upright for a long time. Most often, this syndrome occurs due to CSF fistula in spinal space. Pathophysiology and diagnosis of this disease are poorly known for neurologists and neurosurgeons that can complicate timely surgical care. In case of correct diagnosis, we can identify the exact location of CSF fistula in 90% of cases. Treatment eliminates symptoms of intracranial hypotension and provides functional recovery. The purpose of this article is to describe the diagnostic algorithm and successful microsurgical treatment of a patient with spinal dural CSF fistula Th3-Th4 through posterolateral transdural approach.
Collapse
Affiliation(s)
| | | | - D S Asyutin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - B A Zakirov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | |
Collapse
|
25
|
Konovalov A, Grebenev F, Asyutin D, Zakirov B, Konovalov N, Pronin I, Eliava S, Chaurasia B. Spinal dural cerebrospinal fluid fistula as a cause of spontaneous intracranial hypotension syndrome: Diagnosis and surgical treatment. J Craniovertebr Junction Spine 2023; 14:108-112. [PMID: 37213575 PMCID: PMC10198209 DOI: 10.4103/jcvjs.jcvjs_135_22] [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: 10/23/2022] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) syndrome most often occurs following a cerebrospinal fluid (CSF) fistula that develops in the spinal space. Neurologists and neurosurgeons lack an understanding of the pathophysiology and diagnosis of this disease, which can make timely surgical care difficult. With the correct diagnostic algorithm, it is possible to identify the exact location of the liquor fistula in 90% of cases; subsequent microsurgical treatment can save the patient from the symptoms of intracranial hypotension and restore the ability to work. Female patient, 57 years old, was admitted with SIH syndrome. Magnetic resonance imaging (MRI) of the brain with contrast confirmed signs of intracranial hypotension. Computed tomography (CT) myelography was performed to pinpoint the location of the CSF fistula. The diagnostic algorithm and successful microsurgical treatment of a patient with spinal dural CSF fistula at the Th3-4 level using a posterolateral transdural approach. The patient was discharged on day 3 after the surgery when these complaints regressed completely. At the control examination of the patient 4 months postoperatively, there were no complaints. Identification of the cause and location of spinal the CSF fistula is a complex process that requires several stages of diagnosis. Examination of the entire back with MRI, CT myelography, or subtraction dynamic myelography is recommended. Microsurgical repair of a spinal fistula is an effective method for the treatment of SIH. The posterolateral transdural approach is effective in the repair of a spinal CSF fistula located ventrally in the thoracic spine.
Collapse
Affiliation(s)
| | | | | | | | | | - Igor Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | |
Collapse
|
26
|
Mark IT, Morris PP, Brinjikji W, Madhavan AA, Cutsforth-Gregory JK, Verdoorn JT. Sacral CSF-Venous Fistulas and Potential Imaging Techniques. AJNR Am J Neuroradiol 2022; 43:1824-1826. [PMID: 36328406 DOI: 10.3174/ajnr.a7699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
This is the first study to describe CSF-venous fistulas involving the sacrum, a location that may be underrecognized on the basis of current imaging techniques. We describe a delayed decubitus flat CT myelogram technique that may be useful to identify sacral CSF-venous fistulas.
Collapse
Affiliation(s)
- I T Mark
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | - P P Morris
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | - W Brinjikji
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | - A A Madhavan
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | | | - J T Verdoorn
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| |
Collapse
|
27
|
Mark IT, Amans MR, Shah VN, Narsinh KH, Caton MT, Teixeira S, Dillon WP. Resisted Inspiration: A New Technique to Aid in the Detection of CSF-Venous Fistulas. AJNR Am J Neuroradiol 2022; 43:1544-1547. [PMID: 36137659 PMCID: PMC9575524 DOI: 10.3174/ajnr.a7636] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 06/17/2022] [Accepted: 07/21/2022] [Indexed: 01/26/2023]
Abstract
We describe a technique termed "resisted inspiration" that could be used during myelography to decrease superior vena cava venous pressure and increase lumbar CSF pressure, potentially aiding in the detection of CSF-venous fistulas.
Collapse
Affiliation(s)
- I T Mark
- From the Department of Radiology and Biomedical Imaging (I.T.M., M.R.A., V.N.S., K.H.N., M.T.C., S.T, W.P.D.), University of California, San Francisco, San Francisco, California
- Department of Radiology (I.T.M.), Mayo Clinic, Rochester, Minnesota
| | - M R Amans
- From the Department of Radiology and Biomedical Imaging (I.T.M., M.R.A., V.N.S., K.H.N., M.T.C., S.T, W.P.D.), University of California, San Francisco, San Francisco, California
| | - V N Shah
- From the Department of Radiology and Biomedical Imaging (I.T.M., M.R.A., V.N.S., K.H.N., M.T.C., S.T, W.P.D.), University of California, San Francisco, San Francisco, California
| | - K H Narsinh
- From the Department of Radiology and Biomedical Imaging (I.T.M., M.R.A., V.N.S., K.H.N., M.T.C., S.T, W.P.D.), University of California, San Francisco, San Francisco, California
| | - M T Caton
- From the Department of Radiology and Biomedical Imaging (I.T.M., M.R.A., V.N.S., K.H.N., M.T.C., S.T, W.P.D.), University of California, San Francisco, San Francisco, California
| | - S Teixeira
- From the Department of Radiology and Biomedical Imaging (I.T.M., M.R.A., V.N.S., K.H.N., M.T.C., S.T, W.P.D.), University of California, San Francisco, San Francisco, California
| | - W P Dillon
- From the Department of Radiology and Biomedical Imaging (I.T.M., M.R.A., V.N.S., K.H.N., M.T.C., S.T, W.P.D.), University of California, San Francisco, San Francisco, California
| |
Collapse
|
28
|
Noufal M, Liang CW, Negus J. Transvenous Embolization for Cerebrospinal Fluid-Venous Fistula. A Case Series from a Single Community-Academic Center. World Neurosurg 2022; 168:e613-e620. [DOI: 10.1016/j.wneu.2022.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/11/2022]
|
29
|
Huls SJ, Shlapak DP, Kim DK, Leng S, Carr CM. Utility of Dual-Energy CT to Improve Diagnosis of CSF Leaks on CT Myelography following Lateral Decubitus Digital Subtraction Myelography with Negative Findings. AJNR Am J Neuroradiol 2022; 43:1539-1543. [PMID: 36574327 PMCID: PMC9575522 DOI: 10.3174/ajnr.a7628] [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: 05/23/2022] [Accepted: 07/12/2022] [Indexed: 01/26/2023]
Abstract
CSF leaks, including CSF-venous fistulas, which cause spontaneous intracranial hypotension, remain difficult to diagnose, even on digital subtraction myelography and CT myelography. Dual-energy CT technology has been used to improve diagnostic utility within multiple organ systems. The capability of dual-energy CT to create virtual monoenergetic images can be leveraged to increase conspicuity of contrast in CSF-venous fistulas and direct epidural CSF leakage to improve the diagnostic utility of CT myelography. Six cases (in 5 patients) are shown in which virtual monoenergetic images demonstrate a leak location that was either occult or poorly visible on high- or low-kilovolt series. This clinical report describes the novel application of dual-energy CT for the detection of subtle CSF leaks including CSF-venous fistulas.
Collapse
Affiliation(s)
- S J Huls
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - D P Shlapak
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - D K Kim
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - S Leng
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - C M Carr
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| |
Collapse
|
30
|
Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [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: 12/02/2022]
Abstract
INTRODUCTION Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed. AREAS COVERED The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes. EXPERT OPINION The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.
Collapse
Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
31
|
Mehan WA Jr, Buch K. Imaging, Clinical, and Demographic Differences in Patients With Type III Spinal Cerebrospinal Fluid Leak (Cerebrospinal Venous Fistulas) Compared With Patients With Types I and II Spinal Cerebrospinal Fluid Leak. J Comput Assist Tomogr 2022. [PMID: 36112050 DOI: 10.1097/RCT.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Spinal cerebrospinal fluid (CSF) leaks are an underdiagnosed cause of neurologic symptoms. The most common types of spinal CSF leaks are from dural tears (type I) and meningeal diverticula (type II). Cerebrospinal fluid-venous fistulas (type III) are less common and underrecognized. The purpose of this study was to evaluate the intracranial and spinal imaging findings in patients with types I/II versus type III leaks. MATERIALS AND METHODS This was a retrospective, institutional review board-approved study performed on adult patients between January 2020 to September 2021 with surgically confirmed type I/II/III spinal CSF leak. Patients had preoperative brain magnetic resonance imaging (MRI) with contrast and medical records detailing symptoms and clinical diagnoses. Patients were excluded for nondiagnostic brain MRIs. Demographic and clinical information were recorded. The presence of extra-axial collections, pachymeningeal thickening, brain sagging, and decreased pontomamillary distance were evaluated on MRI. RESULTS Seven patients had type III leaks, and 16 had type I/II leaks. Patients with type III leaks were older (P = 0.0003) and had higher rates of initial misdiagnosis (100% vs 31%) and longer times to correct diagnosis (P = 0.03) compared with type I/II leaks. Intracranial extra-axial collections were never seen with type III leaks but were seen in 50% of type I/II leaks. Pachymeningeal thickening and brainstem sagging occurred in nearly equal frequency between groups. Smaller pontomamillary distances were seen in type III leaks versus type I/II leaks (P = 0.047). CONCLUSIONS When evaluating patients with suspected spinal CSF leak, findings of older age, absence of intracranial extra-axial collections, and small pontomamillary distances may raise suspicion for type III versus type I/II leak.
Collapse
|
32
|
Bergui M, Mistretta F, Bosco G, Cester G, Chioffi F, Gambino A, Molinaro S, Russo R, Sorarù G, Causin F. CSF-venous leak responsible for spontaneous intracranial hypotension treated by endovascular venous route: First cases in Italy. Interv Neuroradiol 2022:15910199221116011. [PMID: 35861992 DOI: 10.1177/15910199221116011] [Citation(s) in RCA: 2] [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] [Indexed: 11/17/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is due to a leakage of CSF lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. Clinical and MRI are usually typical enough to allow diagnosis, while finding the location of the dural breach is challenging. Since some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic path has been proposed. Here we report the first two successfully treated patients in Italy. Both had chronic and non specific symptoms, with severe reduction of quality of life; clinical symptoms improved after endovascular occlusion of the responsible vein.
Collapse
Affiliation(s)
- Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Francesco Mistretta
- Department of Surgical Sciences, Radiology Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giovanni Bosco
- Department of Neuroscience, Stroke Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giacomo Cester
- Neuroradiology Unit, University Hospital of Padova, Padua, Italy
| | - Franco Chioffi
- Neurosurgery Unit, University Hospital of Padova, Padua, Italy
| | - Andrea Gambino
- Department of Surgical Sciences, Radiology Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Gianni Sorarù
- Neurology Unit, Department of Neuroscience, 18624Azienda Ospedaliera di Padova, Padua, Italy
| | - Francesco Causin
- Neuroradiology Unit, University Hospital of Padova, Padua, Italy
| |
Collapse
|
33
|
Mamlouk MD, Shen PY, Jun P, Sedrak MF. Spontaneous Spinal CSF Leaks Stratified by Age, Body Mass Index, and Spinal Level. AJNR Am J Neuroradiol 2022; 43:1068-1072. [PMID: 35738670 DOI: 10.3174/ajnr.a7548] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/29/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There are 3 main types of spinal CSF leaks, and the imaging appearances are well-reported. Specific patient demographics and spinal locations of the various types of spinal leaks are less frequently described. The purpose of this article was to stratify the various types of spontaneous CSF leaks on the basis of age, body mass index, and spinal level. MATERIALS AND METHODS Retrospective review was performed for all patients with spontaneous spinal CSF leaks identified on CT myelography. Age, body mass index, and spinal CSF leak type and level were recorded. RESULTS Sixty-five patients (37 women and 28 men) had spinal CSF leaks. Type 1 CSF leaks (dural tears) were observed in 25 patients (mean age, 44.5 years; mean body mass index, 24.3) and were most common in the upper thoracic spine (72%), particularly at the T1-T2 level (36%). Type 2 CSF leaks (ruptured meningeal diverticula) were observed in 4 patients (mean age, 45.5 years; mean body mass index, 27.5) and were all seen in the lower thoracic spine. Type 3 CSF leaks (CSF-venous fistulas) were observed in 36 patients (mean age, 58.8 years; mean body mass index, 27.0) and were most common on the right side (72%) and in the lower thoracic spine (56%). CONCLUSIONS Type 1 CSF leaks occurred in younger patients with a normal body mass index, while patients with type 3 CSF leaks were relatively older and had an elevated body mass index. Type 1 leaks mostly occurred in the upper thoracic spine, and types 2 and 3 leaks mostly occurred in the lower thoracic spine.
Collapse
Affiliation(s)
- M D Mamlouk
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), 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
| | - P Y Shen
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - P Jun
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - M F Sedrak
- Department of Neurosurgery (M.F.S.), The Permanente Medical Group, Kaiser Permanente Medical Center, Redwood City, Redwood City, California
| |
Collapse
|
34
|
Madhavan AA, Cutsforth-Gregory JK, Oushy SH, Borg N, Brinjikji W. Combined CSF-venous Fistula and middle meningeal artery embolization for treatment of spontaneous intracranial hypotension. Interv Neuroradiol 2022:15910199221109044. [PMID: 35712963 DOI: 10.1177/15910199221109044] [Citation(s) in RCA: 2] [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] [Indexed: 11/15/2022] Open
Abstract
Transvenous Onyx embolization was recently described as an effective treatment of spontaneous intracranial hypotension caused by CSF-venous fistulas. Patients with CSF-venous fistulas can present with a wide spectrum of clinical and imaging findings, sometimes including spontaneous subdural hematomas, subdural hygromas, or a combination of both. Here, we describe four patients with spontaneous intracranial hypotension complicated by subdural fluid collections caused by CSF-venous fistulas. The patients were treated with transvenous Onyx embolization of their CSF-venous fistulas and transarterial particle embolization of the bilateral middle meningeal arteries, with both procedures performed in a single treatment session. All four patients had clinical improvement and decreased size or resolution of their subdural fluid collections. Based on our findings, we believe that middle meningeal embolization could be a useful adjunct to CSF-venous fistula embolization. A case-control study comparing patients who did or did not undergo middle meningeal embolization will be necessary to validate this supposition.
Collapse
Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | | | - Soliman H Oushy
- Department of Neurosurgery, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Nicholas Borg
- Department of Neurosurgery, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Waleed Brinjikji
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| |
Collapse
|
35
|
Sarker A, Suh M, Choi Y, Park JY, Kwon S, Kim H, Lee E, Seo H, Lee Y, Lee DS. [64Cu]Cu-Albumin Clearance Imaging to Evaluate Lymphatic Efflux of Cerebrospinal Space Fluid in Mouse Model. Nucl Med Mol Imaging. [DOI: 10.1007/s13139-022-00746-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 10/18/2022] Open
|
36
|
Carlton Jones L, Goadsby PJ. Same-Day Bilateral Decubitus CT Myelography for Detecting CSF-Venous Fistulas in Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2022; 43:645-648. [PMID: 35332017 PMCID: PMC8993205 DOI: 10.3174/ajnr.a7476] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/07/2022] [Indexed: 12/26/2022]
Abstract
Lateral decubitus CT myelography is a sensitive technique for detecting CSF-venous fistulas in patients with spontaneous intracranial hypotension. It might be necessary to perform bilateral studies to locate a fistula. We report on the feasibility of obtaining diagnostic-quality bilateral decubitus CT myelography in a single session, avoiding the need to schedule separate examinations for the left and right sides on different days.
Collapse
Affiliation(s)
- L Carlton Jones
- From the Department of Radiology (L.C.J.), Guy's and St. Thomas's Hospitals National Health Service Foundation Trust, St. Thomas' Hospital, London, UK .,Department of Neuroradiology (L.C.J.), King's College Hospital National Health Service Foundation Trust, London, UK
| | - P J Goadsby
- National Institute for Health Research Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College Hospital, London, UK
| |
Collapse
|
37
|
Dobrocky T, Nicholson P, Häni L, Mordasini P, Krings T, Brinjikji W, Cutsforth-gregory JK, Schär R, Schankin C, Gralla J, Pereira VM, Raabe A, Farb R, Beck J, Piechowiak EI. Spontaneous intracranial hypotension: searching for the CSF leak. Lancet Neurol 2022. [DOI: 10.1016/s1474-4422(21)00423-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
|
38
|
Brinjikji W, Garza I, Whealy M, Kissoon N, Atkinson JLD, Savastano L, Madhavan A, Cutsforth-Gregory J. Clinical and imaging outcomes of cerebrospinal fluid-venous fistula embolization. J Neurointerv Surg 2022; 14:953-956. [DOI: 10.1136/neurintsurg-2021-018466] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/23/2021] [Indexed: 11/04/2022]
Abstract
BackgroundWe report outcomes of spontaneous intracranial hypotension (SIH) patients who underwent transvenous embolization of cerebrospinal fluid-venous fistulas (CSFVFs) confirmed on digital subtraction myelography (DSM) performed at our institution.MethodsThis is a retrospective evaluation of a prospectively collected database of SIH patients who underwent transvenous embolization of CSFVFs. Only patients who had fistulas confirmed on DSM performed at our institution were included. All patients had a baseline MRI and an MRI performed at least 90 days post-embolization, as well as clinical evaluation using the six item Headache Impact Test (HIT-6) and the Patient Global Impression of Change (PGIC) scales. Paired t-test was used to report changes in Bern MRI scores and HIT-6 scores at follow-up.Results40 patients were included (29 female, 11 male). Mean age was 57.4±10.3 years. Mean Bern score improved from 5.7±3.0 at baseline to 1.3±2.0 at follow-up (p<0.0001). Mean HIT-6 score at baseline was 67.2±11.1 and at follow-up was 41.5±10.1 (p<0.0001). Median PGIC was 1, with 36 patients (90.0%) reporting at least minimal improvement and 32 patients (82.5%) reporting much or very much improvement. Complications included persistent local site pain in 12 patients (30%), suspected rebound intracranial hypertension requiring medical intervention in 7 patients (17.5%), and asymptomatic tiny Onyx emboli to the lungs in 3 patients (7.5%).ConclusionsTransvenous embolization of CSFVFs using Onyx is safe and effective, resulting in significant improvement in headache and overall clinical outcomes in nearly 90% of patients, and substantial improvements in brain MRI abnormalities.
Collapse
|
39
|
Konovalov AN, Vinogradov EV, Grebenev FV, Batalov AI, Shevchenko KV, Pronin IN, Konovalov NA. [Spinal CSF-venous fistula: case report and literature review]. Zh Vopr Neirokhir Im N N Burdenko 2022; 86:41-49. [PMID: 35758077 DOI: 10.17116/neiro20228603141] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
UNLABELLED Syndrome of spontaneous intracranial hypotension is increasingly described in the literature as a multifactorial disease with impairment of the quality of life and risk of mortality. CSF-venous fistula as a cause of intracranial hypotension syndrome is extremely rare and requires complex diagnosis and timely surgical treatment. OBJECTIVE We present a 55-year-old patient with acute spontaneous intracranial hypotension and spinal CSF-venous fistula. Literature data are also analyzed. RESULTS Algorithm for diagnosis and efficacy of microsurgical resection of CSF-venous fistula is demonstrated. CONCLUSION Intracranial hypotension following spinal fistula requires careful examination. Accurate understanding of pathophysiological and anatomical features of this disease is necessary to select an effective treatment method.
Collapse
Affiliation(s)
| | | | | | - A I Batalov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | |
Collapse
|
40
|
Carlton Jones L, Butteriss D, Scoffings D. Spontaneous intracranial hypotension: the role of radiology in diagnosis and management. Clin Radiol 2021:S0009-9260(21)00536-5. [PMID: 34949452 DOI: 10.1016/j.crad.2021.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/09/2021] [Indexed: 12/26/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is a condition that results from leakage of cerebrospinal fluid (CSF) from the spine, and which typically presents with debilitating orthostatic headache, but can be associated with a wide range of other symptoms. The causes of spontaneous CSF leaks that lead to SIH include dural tears, leaking meningeal diverticula, and CSF-venous fistulas. Imaging plays a central role in the initial diagnosis of SIH and in its subsequent investigation and management. This article reviews the typical neuroimaging manifestations of SIH and discusses the utility of different myelographic techniques for localising spinal CSF leaks as well as the role of image-guided treatment.
Collapse
|
41
|
Roytman M, Ulrich CT, Chazen JL. Post-dural puncture pseudomeningocele ("arachnoid bleb"): An underrecognized etiology of spontaneous intracranial hypotension symptomatology. Clin Imaging 2021; 80:377-381. [PMID: 34517304 DOI: 10.1016/j.clinimag.2021.08.023] [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] [Received: 07/01/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an important secondary cause of a persistent headache syndrome, classically presenting as sudden onset debilitating positional headaches related to reduced intracranial cerebrospinal fluid (CSF) volume. Current understanding of SIH pathogenesis recognizes three underlying etiologies: dural tear, meningeal diverticulum, and CSF-venous fistula, with a fourth broad category of indeterminate/unknown etiologies. Post-dural puncture headache (PDPH) is a well-known and common complication of dural puncture, typically remitting spontaneously within two weeks of onset or with autologous epidural blood patch, though with some patients developing complex and difficult to manage chronic PDPH. Herein, we present a case of chronic PDPH resulting in SIH symptomatology secondary to a post-dural puncture pseudomeningocele, or "arachnoid bleb," successfully treated with curative surgical intervention. Increasing awareness of additional potential etiologies of SIH symptomatology will allow for improved detection for targeted definitive therapy, ultimately improving patient outcomes including quality of life in this debilitating and difficult to manage secondary headache syndrome.
Collapse
Affiliation(s)
- Michelle Roytman
- Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Medicine, United States of America
| | | | - J Levi Chazen
- Department of Radiology, Hospital for Special Surgery, United States of America.
| |
Collapse
|
42
|
Luetzen N, Dovi-Akue P, Fung C, Beck J, Urbach H. Spontaneous intracranial hypotension: diagnostic and therapeutic workup. Neuroradiology 2021; 63:1765-1772. [PMID: 34297176 PMCID: PMC8528761 DOI: 10.1007/s00234-021-02766-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with typical MRI findings among which engorgement of the venous sinuses, pachymeningeal enhancement, and effacement of the suprasellar cistern have the highest diagnostic sensitivity. SIH is in almost all cases caused by spinal CSF leaks. Spinal MRI scans showing so-called spinal longitudinal extradural fluid (SLEC) are suggestive of ventral dural tears (type 1 leak) which are located with prone dynamic (digital subtraction) myelography. As around half of the ventral dural tears are located in the upper thoracic spine, additional prone dynamic CT myelography is often needed. Leaking nerve root sleeves typically associated with meningeal diverticulae (type 2 leaks) and CSF-venous fistulas (type 3 leaks) are proven via lateral decubitus dynamic digital subtraction or CT myelography: type 2 leaks are SLEC-positive if the tear is proximal and SLEC-negative if it is distal, and type 3 leaks are always SLEC-negative. Although 30–70% of SIH patients show marked improvement following epidural blood patches applied via various techniques definite cure mostly requires surgical closure of ventral dural tears and surgical ligations of leaking nerve root sleeves associated with meningeal diverticulae or CSF-venous fistulas. For the latter, transvenous embolization with liquid embolic agents via the azygos vein system is a novel and valuable therapeutic alternative.
Collapse
Affiliation(s)
- Niklas Luetzen
- Department of Neuroradiology, Medical Center, University of Freiburg, Breisacher Str. 64 , 79106, Freiburg, Germany
| | - Philippe Dovi-Akue
- Department of Neuroradiology, Medical Center, University of Freiburg, Breisacher Str. 64 , 79106, Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Juergen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, University of Freiburg, Breisacher Str. 64 , 79106, Freiburg, Germany.
| |
Collapse
|
43
|
Madhavan AA, Carr CM, Benson JC, Brinjikji W, Diehn FE, Kim DK, Lehman VT, Liebo GB, Morris PP, Shlapak DP, Verdoorn JT, Morris JM. Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization. Clin Neuroradiol 2021; 32:537-545. [PMID: 34292360 DOI: 10.1007/s00062-021-01060-y] [Citation(s) in RCA: 3] [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: 02/27/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intrathecal gadolinium magnetic resonance (MR) myelography can be used to localize various types of spinal cerebrospinal fluid (CSF) leaks; however, its diagnostic yield is not well known. We sought to determine the diagnostic yield of MR myelography in patients with spontaneous intracranial hypotension. METHODS A retrospective review was performed on all patients who had undergone intrathecal gadolinium MR myelography at our institution from 2002 to 2020 for suspected spinal CSF leak. The MR myelography images were reviewed for the presence or absence of a spinal CSF leak site. Images were also evaluated for the presence an extradural fluid collection. RESULTS A total of 97 patients were included in the final cohort. The average age was 52.6 years; 67.0% were female, 4 patients underwent 2 examinations each, yielding a total of 101 MR myelograms. The source of a spinal CSF leak was localized in 14 patients. The diagnostic yield for CSF leak localization on intrathecal gadolinium MR myelography was 14/101 (13.9%) per GdM examination and 14/97 (14.4%) per patient. Among the subset of patients without extradural fluid collections, the yield was 15.7% per examination. All detected leaks were either CSF-venous fistulas or distal nerve root sleeve tears. CONCLUSION Intrathecal gadolinium MR myelography is capable of localizing CSF-venous fistulas and distal nerve root sleeve tears; however, our data show that it has a limited diagnostic yield. We suggest that other modalities may be a better first step before attempting intrathecal gadolinium MR myelography.
Collapse
Affiliation(s)
- Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA.
| | - Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Greta B Liebo
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Pearse P Morris
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Jonathan M Morris
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| |
Collapse
|
44
|
Abstract
CSF-venous fistulas (CVFs), first described in 2014, represent an important cause of spontaneous intracranial hypotension (SIH). CVFs can be challenging to detect on conventional anatomic imaging because, unlike other types of spinal CSF leak, they do not typically result in pooling of fluid in the epidural space, and imaging signs of CVF may be subtle. Specialized myelographic techniques have been developed to help with CVF identification, but these techniques are not yet widely disseminated. This article reviews the current understanding of CVFs, emphasizing correlations between venous anatomy and imaging findings as well as potential mechanisms for pathogenesis, and describes current imaging techniques used for CVF diagnosis and localization. These techniques are broadly classified into fluoroscopy-based methods, including digital subtraction myelography and dynamic myelography, as well as cross-sectional methods, including decubitus CT myelography and MR myelography with intrathecal gadolinium. Knowledge of these various options, including their relative advantages and disadvantages, is critical in the care of patients with SIH. Investigation is ongoing, and continued advances are anticipated in understanding of CVFs as well as in optimal imaging detection.
Collapse
|
45
|
Abstract
Spontaneous intracranial hypotension typically manifests with orthostatic headaches and is caused by spinal dural tears, ruptured meningeal diverticula, or CSF-venous fistulas. While most patients are diagnosed and treated in the outpatient setting, some patients will occasionally present in the emergent ICU setting due to subdural hematomas, coma, or downward brain herniation. In this review paper, we will discuss the diagnostic and treatment steps that intensivists can undertake to coordinate a team approach to successfully manage these patients. A brief general overview of spontaneous intracranial hypotension will also be discussed.
Collapse
Affiliation(s)
- Mark D Mamlouk
- Department of Radiology, The Permanente Medical Group, 23545Kaiser Permanente Medical Center, Santa Clara, CA, USA.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Peter Y Shen
- Department of Radiology, The Permanente Medical Group, 23545Kaiser Permanente Medical Center, Santa Clara, CA, USA
| | - Mark F Sedrak
- Department of Neurosurgery, The Permanente Medical Group, 23545Kaiser Permanente Medical Center, Redwood City, CA, USA
| |
Collapse
|
46
|
Abstract
Headache is a common reason for seeking medical attention. Most cases are benign primary headache disorders; however, there is significant overlap between symptoms of these disorders and secondary headaches. Differentiating these clinical scenarios requires a careful history with attention to red flag symptoms and a neurologic examination. These details can identify dangerous disorders: subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, elevated intracranial pressure, hydrocephalus, cerebral venous sinus thrombosis, arterial dissection, central nervous system infection, and inflammatory vasculitis. Older, pregnant, or immunocompromised patients have a higher risk for secondary disorders; clinicians should have a different threshold to conduct evaluations in such patients.
Collapse
Affiliation(s)
- David Kopel
- Department of Neurology, 725 Albany Street, Suite 7B, Boston, MA 02118, USA
| | - Crandall Peeler
- Department of Ophthalmology and Neurology, 85 East Concord Street 8th Floor, Boston, MA 02118, USA
| | - Shuhan Zhu
- Department of Neurology, 725 Albany Street, Suite 7B, Boston, MA 02118, USA.
| |
Collapse
|
47
|
Affiliation(s)
- Mark D. Mamlouk
- From the Department of Radiology, The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, 700 Lawrence Expy, Santa Clara, CA 95051 (M.D.M., P.Y.S.); Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, Calif (M.D.M., W.P.D.); and Department of Neurosurgery, The Permanente Medical Group, Kaiser Permanente Medical Center, Redwood City, Redwood City, Calif (M.F.S.)
| | - Peter Y. Shen
- From the Department of Radiology, The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, 700 Lawrence Expy, Santa Clara, CA 95051 (M.D.M., P.Y.S.); Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, Calif (M.D.M., W.P.D.); and Department of Neurosurgery, The Permanente Medical Group, Kaiser Permanente Medical Center, Redwood City, Redwood City, Calif (M.F.S.)
| | - Mark F. Sedrak
- From the Department of Radiology, The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, 700 Lawrence Expy, Santa Clara, CA 95051 (M.D.M., P.Y.S.); Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, Calif (M.D.M., W.P.D.); and Department of Neurosurgery, The Permanente Medical Group, Kaiser Permanente Medical Center, Redwood City, Redwood City, Calif (M.F.S.)
| | - William P. Dillon
- From the Department of Radiology, The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, 700 Lawrence Expy, Santa Clara, CA 95051 (M.D.M., P.Y.S.); Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, Calif (M.D.M., W.P.D.); and Department of Neurosurgery, The Permanente Medical Group, Kaiser Permanente Medical Center, Redwood City, Redwood City, Calif (M.F.S.)
| |
Collapse
|
48
|
Brinjikji W, Savastano LE, Atkinson JLD, Garza I, Farb R, Cutsforth-Gregory JK. A Novel Endovascular Therapy for CSF Hypotension Secondary to CSF-Venous Fistulas. AJNR Am J Neuroradiol 2021; 42:882-887. [PMID: 33541895 DOI: 10.3174/ajnr.a7014] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/30/2020] [Indexed: 11/07/2022]
Abstract
We report a consecutive case series of patients who underwent transvenous embolization of the paraspinal vein, which was draining the CSF-venous fistula, for treatment of spontaneous intracranial hypotension. These are the first-ever reported cases of this treatment for CSF-venous fistulas. All patients underwent spinal venography following catheterization of the azygous vein and then selective catheterization of the paraspinal vein followed by embolization of the vein with Onyx. All patients had improvement of clinical and radiologic findings with 4 patients having complete resolution of headaches and 1 patient having 50% reduction in headache symptoms. Pachymeningeal enhancement resolved in 4 patients and improved but did not resolve in 1 patient. Brain sag resolved in 4 patients and improved but did not resolve in 1 patient. There were no cases of permanent neurologic complications. All patients were discharged home on the day of the procedure.
Collapse
Affiliation(s)
- W Brinjikji
- Department of Interventional Neuroradiology (W.B., L.E.S.), Mayo Clinic, Rochester, Minnesota .,Department of Neurosurgery (W.B., L.E.S., J.L.D.A.), Mayo Clinic, Rochester, Minnesota
| | - L E Savastano
- Department of Interventional Neuroradiology (W.B., L.E.S.), Mayo Clinic, Rochester, Minnesota.,Department of Neurosurgery (W.B., L.E.S., J.L.D.A.), Mayo Clinic, Rochester, Minnesota
| | - J L D Atkinson
- Department of Neurosurgery (W.B., L.E.S., J.L.D.A.), Mayo Clinic, Rochester, Minnesota
| | - I Garza
- Department of Neurology (I.G., J.K.C.-G.), Mayo Clinic, Rochester, Minnesota
| | - R Farb
- Joint Department of Medical Imaging (R.F.), Toronto Western Hospital, Toronto, Ontario, Canada
| | | |
Collapse
|
49
|
Nagesh CP, Devaraj R, Joshi G, Shafi P, Krishna KN, Satischandra P. The importance of repeat digital subtraction myelography in the diagnosis of cryptogenic CSF-venous fistula causing spontaneous intracranial hypotension. Interv Neuroradiol 2021; 27:727-732. [PMID: 33525918 DOI: 10.1177/1591019921991398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 11/15/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a rare disorder that occurs secondary to acquired cerebrospinal fluid (CSF) leaks in the spine. Treatment involves either an epidural blood patch or surgical ligation. Essential to the selecting the optimal management strategy is classifying the type of leak and accurate localization of its level. Hitherto, this has been achieved using conventional imaging methods such as static CT or MR myelography which are adequate for the demonstration of only high flow leaks. Digital subtraction myelography (DSM) is a novel technique which provides superior temporal and spatial resolution in the localization of more challenging slow flow leaks. However, DSM may also be initially non-diagnostic. We report a case of SIH in which repeat DSM revealed a type 3 CSF-venous fistula and demonstrate a possible mechanism of transient CSF leak block resulting in the initial false negative findings based on morphological changes in the culprit nerve sheath diverticulum-pseudomeningocoele complex. The patient underwent successful surgical ligation with clinicoradiological resolution of SIH.
Collapse
Affiliation(s)
- Chinmay P Nagesh
- Department of Neuroendovascular and Interventional Radiology, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - Rashmi Devaraj
- Department of Neurology, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - Girish Joshi
- Department of Neurosurgery, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - Peerzada Shafi
- Department of Neurology, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - K N Krishna
- Department of Neurosurgery, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | | |
Collapse
|
50
|
Abstract
PURPOSE OF REVIEW To provide an update on recent developments in the understanding, diagnosis, and treatment of CSF-venous fistula (CVF). RECENT FINDING CVF is a recently recognized cause of spontaneous intracranial hypotension (SIH), an important secondary headache, in which an aberrant connection is formed between the spinal subarachnoid space and an adjacent spinal epidural vein permitting unregulated loss of CSF into the circulatory system. CVFs often occur without a concurrent epidural fluid collection; therefore, CVF should be considered as a potential etiology for patients with SIH symptomatology but without an identifiable CSF leak. Imaging plays a critical role in the detection and localization of CVFs, with a number of imaging techniques and provocative maneuvers described in the literature to facilitate their localization for targeted and definitive treatment. Increasing awareness and improving the localization of CVFs can allow for improved outcomes in the SIH patient population. Future prospective studies are needed to determine the diagnostic performance of currently available imaging techniques as well as their ability to inform workup and guide treatment decisions.
Collapse
Affiliation(s)
- Michelle Roytman
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Gayle Salama
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Matthew S Robbins
- Department of Neurology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - J Levi Chazen
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA.
| |
Collapse
|