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Madhavan AA, Brinjikji W, Cutsforth-Gregory JK, Amrhein TJ, Kranz PG, Benson JC, Diehn FE, Johnson-Tesch BA, Liebo GB, Lehman VT, Mark IT, Morris PP, Oien MP, Shlapak DP, Verdoorn JT. Myelographic Techniques for the Localization of CSF-Venous Fistulas: Updates in 2024. AJNR Am J Neuroradiol 2024:ajnr.A8299. [PMID: 39089875 DOI: 10.3174/ajnr.a8299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 08/04/2024]
Abstract
CSF-venous fistulas (CVFs) are a common cause of spontaneous intracranial hypotension. Despite their relatively frequent occurrence, they can be exceedingly difficult to detect on imaging. Since the initial description of CVFs in 2014, the recognition and diagnosis of this type of CSF leak has continually increased. As a result of multi-institutional efforts, a wide spectrum of imaging modalities and specialized techniques for CVF detection is now available. It is important for radiologists to be familiar with the multitude of available techniques, because each has unique advantages and drawbacks. In this article, we review the spectrum of imaging modalities available for the detection of CVFs, explain the advantages and disadvantages of each, provide typical imaging examples, and discuss provocative maneuvers that may improve the conspicuity of CVFs. Discussed modalities include conventional CT myelography, dynamic myelography, digital subtraction myelography, conebeam CT myelography, decubitus CT myelography by using conventional energy-integrating detector scanners, decubitus photon counting CT myelography, and intrathecal gadolinium MR myelography. Additional topics to be discussed include optimal patient positioning, respiratory techniques, and intrathecal pressure augmentation.
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Affiliation(s)
- Ajay A Madhavan
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Waleed Brinjikji
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | | | - Timothy J Amrhein
- Division of Neuroradiology, Department of Radiology (T.J.A., P.G.K.), Duke Health, Durham, North Carolina
| | - Peter G Kranz
- Division of Neuroradiology, Department of Radiology (T.J.A., P.G.K.), Duke Health, Durham, North Carolina
| | - John C Benson
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Felix E Diehn
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ben A Johnson-Tesch
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Greta B Liebo
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Vance T Lehman
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ian T Mark
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Pearse P Morris
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Michael P Oien
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Darya P Shlapak
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Jared T Verdoorn
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
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2
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Loewenstern J, McMahon P, Wang D, Schweitzer AD, Salama G, Strauss S. Clinical utility of CT myelography renal collecting system density in the evaluation of spinal CSF leak or CSF-venous connection in patients with spontaneous intracranial hypotension. Neuroradiology 2024:10.1007/s00234-024-03426-8. [PMID: 39030336 DOI: 10.1007/s00234-024-03426-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 07/05/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Identifying spontaneous CSF leaks can be difficult on CT myelography (CTM) in patients with suspected spontaneous intracranial hypotension (SIH). The current study compared renal collecting system (RCS) density during CTM in patients with suspected SIH relative to non-SIH controls and evaluated the overall utility as an indirect sign of spontaneous CSF leak in patients with SIH. METHODS All CTM performed over an 8-year period (n = 392) were retrospectively reviewed and included cases (n = 295) were divided into groups consisting of SIH patients with (n = 35) or without (n = 77) confirmed CSF leak on CTM and non-SIH controls (n = 183). Average and relative average (relative to systemic contrast density) RCS densities were compared with multivariate analysis adjusting for patient characteristics and CTM technical differences. RESULTS Average RCS densities were greater for confirmed versus non-confirmed SIH groups and greater for both SIH groups relative to non-SIH controls. Correlations between RCS density and time from injection to CTM were higher within SIH patient groups compared to controls. Measured RCS density had a higher negative predictive value for excluding CSF leak both within the SIH patient groups as well as the overall cohort (84% and 96%, respectively), with optimized thresholds yielding 80% sensitivity and 70% specificity for the presence of leak in the overall cohort. CONCLUSION Accounting for RCS density may provide reliable additional indirect diagnostic value about the suspicion of a CSF leak in patients undergoing CTM for evaluation of SIH symptoms.
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Affiliation(s)
- Joshua Loewenstern
- Department of Radiology, New York Presbyterian Hospital - Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA.
| | - Pierce McMahon
- Department of Radiology, New York Presbyterian Hospital - Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA
| | - Daiqi Wang
- Department of Radiology, New York Presbyterian Hospital - Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA
| | - Andrew D Schweitzer
- Department of Radiology, New York Presbyterian Hospital - Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA
| | - Gayle Salama
- Department of Radiology, New York Presbyterian Hospital - Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA
| | - Sara Strauss
- Department of Radiology, New York Presbyterian Hospital - Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA
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3
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Sung J, Lin M, Giantini-Larsen A, Kim A, Edasery D, Roytman M, Strauss S, Schweitzer AD, Park JK, Salama G. Cerebrospinal Fluid Leaks: Challenges in Localizing Spontaneous Spinal Leak Sites and Minimally Invasive Treatment. World Neurosurg 2024; 187:294-303. [PMID: 38970200 DOI: 10.1016/j.wneu.2024.03.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 07/08/2024]
Abstract
The confirmation of cerebrospinal fluid (CSF) leaks in the setting of spontaneous intracranial hypotension (SIH) by imaging involves a growing toolset of multimodal advanced spinal and skull base imaging techniques, for which exists a unique set of challenges for each CSF leak type. Furthermore, the repertoire of minimally invasive CSF leak treatment beyond nontargeted epidural blood patch administration has grown widely, with varied practices across institutions. This review describes current diagnostic imaging and treatment modalities as they apply to the challenges of CSF leak localization and management.
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Affiliation(s)
- Jeffrey Sung
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Matthew Lin
- Weill Cornell Medical College, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Andrew Kim
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - David Edasery
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Michelle Roytman
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Sara Strauss
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Andrew D Schweitzer
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - John K Park
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA; Department of Neurological Surgery, NewYork-Presbyterian Queens Hospital, Queens, New York, USA
| | - Gayle Salama
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA.
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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 2024; 30:428-432. [PMID: 35861992 PMCID: PMC11310726 DOI: 10.1177/15910199221116011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [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.
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Affiliation(s)
- Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Francesco Mistretta
- Department of Surgical Sciences, Radiology Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giovanni Bosco
- Department of Neuroscience, Stroke Unit, University of Turin, Azienda 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, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Gianni Sorarù
- Neurology Unit, Department of Neuroscience, Azienda Ospedaliera di Padova, Padua, Italy
| | - Francesco Causin
- Neuroradiology Unit, University Hospital of Padova, Padua, Italy
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Schartz D, Ellens N, Ismail R, Houk C, Kessler A, Ellika S, Bender MT. Prevalence of SLEC-negative spontaneous intracranial hypotension in patients with spinal nerve root sleeve diverticula on MRI. Neuroradiol J 2023; 36:736-739. [PMID: 37589060 PMCID: PMC10649535 DOI: 10.1177/19714009231196467] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
PURPOSE While there is thought to be an association between spinal nerve root diverticula (NRD) and spontaneous intracranial hypotension (SIH) without a spinal longitudinal epidural collection (SLEC), it remains unclear what the overall prevalence of SLEC-negative SIH is in patients with NRD on MRI. METHODS Spine MRI imaging reports from our single institution were electronically screened for instances of NRD over a 9-year period (2016-2023). From these cases, patients with brain MRIs consistent with SIH were also identified. Subsequently, the overall proportion of SLEC-negative SIH was determined as a function of total cases with NRD based on spinal level. RESULTS In total, 83,843 patients with spinal MRIs were screened which identified 4174 (4.97%) with NRD. From these, there were 1203 cervical, 622 thoracic, and 2979 lumbosacral spine MRIs. In total, 16 patients (0.38%; Standard Error [SE]: 0.48%-0.28%) had a brain MRI compatible with SLEC-negative SIH and met ICHD-3 criteria. Patients with cervical NRD had SIH in 2 cases (0.16%; SE: 0.27%-0.05%). SLEC-negative SIH was present in 11 patients with lumbosacral NRD (0.34%; SE: 0.44%-0.24%). In patients with diverticula in the thoracic spine, 14 (2.3%; SE: 2.8%-1.8%) had SLEC-negative SIH. SLEC-negative SIH was significantly more prevalent in patients with thoracic diverticula compared to those with cervical (p<.0001) or lumbosacral NRD (p<.0001). CONCLUSION In patients with spinal NRD, concurrent SLEC-negative SIH is present in approximately 0.38% of patients, suggesting that in the vast majority of cases, they are an incidental finding. However, SIH is present in approximately 2.3% of patients with thoracic NRD and may be more specific for leak localization.
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Affiliation(s)
- Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, USA
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Clifton Houk
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Shehanaz Ellika
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, USA
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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] [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.
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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
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Stuebe C, Jones BA, Syal A, Rahme RJ, Turcotte EL, Toussaint LG, Ross JS, Bendok BR. Cerebrospinal Venous Fistula Presenting with Cognitive Decline: Systematic Literature Review and Report of Two Cases. World Neurosurg 2023; 176:74-80. [PMID: 36934870 DOI: 10.1016/j.wneu.2023.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE A cerebrospinal fluid (CSF) venous fistula (CVF) is an aberrant connection between the subarachnoid space and a vein resulting in CSF loss. The presentation and management of CVF with cognitive decline is incompletely understood. METHODS A systematic review was completed following the PRISMA guidelines. Articles that included at least 1 case of imaging-confirmed CVF with details on patient treatment were included. A separate review of cases of patients with spontaneous intracranial hypotension (SIH) with frontotemporal dementia (FTD) or dementia symptoms was also completed. RESULTS Ten CVF articles (69 patients; average age, 51.5 years) and 5 SIH with FTD or dementia articles (n = 41; average age, 55.9 years) were identified. Only 1 patients with CVF with cognitive abnormalities was identified. The most common symptom was headache in both reviews. Brain sag was identified in all patients, whereas CSF leak was identified in only 2 patients with SIH with FTD or dementia (4.9%). An epidural blood or fibrin glue patch was used in all patients with CVF and in 33 patients with SIH with FTD or dementia. Fifty-five patients with CVF (79.7%) and 27 patients with SIH with FTD or dementia (65.9%) had surgery. CONCLUSIONS The 2 cases and literature reviews show the difficulty in diagnosis and treatment of CVF with cognitive decline. Novel imaging techniques should be used in patients with cognitive decline in whom a CSF leak is suspected. Transvenous embolization or surgery should be considered before patching for treatment of CVF-induced brain sag and resulting dementia.
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Affiliation(s)
- Caren Stuebe
- Texas A&M College of Medicine, Bryan, Texas, USA
| | - Breck A Jones
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-Therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Arjun Syal
- New York Medical College, Valhalla, New York, USA
| | - Rudy J Rahme
- Department of Neurosurgery, Global Neuroscience Institute, Philadelphia, Pennsylvania, USA
| | - Evelyn L Turcotte
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-Therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - L Gerard Toussaint
- Texas A&M College of Medicine, Bryan, Texas, USA; Texas Brain and Spine Institute, Bryan, Texas, USA
| | - Jeffrey S Ross
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-Therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA; Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA.
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8
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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: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [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.
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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.)
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9
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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] [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.
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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
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10
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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] [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.
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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
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11
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Konovalov AN, Gadzhiagaev V, Vinogradov EV, Nikitin NY, Eliava SS, Konovalov NA. Surgical treatment efficacy of CSF-venous fistulas: systematic review. World Neurosurg 2022; 161:91-96. [PMID: 35176526 DOI: 10.1016/j.wneu.2022.02.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 11/24/2022]
Affiliation(s)
- A N Konovalov
- N. N. Burdenko National medical research center of neurosurgery of the Ministry of Health of the Russian Federation (BNC)
| | - Vadim Gadzhiagaev
- N. N. Burdenko National medical research center of neurosurgery of the Ministry of Health of the Russian Federation (BNC)
| | - E V Vinogradov
- N. N. Burdenko National medical research center of neurosurgery of the Ministry of Health of the Russian Federation (BNC)
| | - N Y Nikitin
- N. N. Burdenko National medical research center of neurosurgery of the Ministry of Health of the Russian Federation (BNC)
| | - Sh Sh Eliava
- N. N. Burdenko National medical research center of neurosurgery of the Ministry of Health of the Russian Federation (BNC)
| | - N A Konovalov
- N. N. Burdenko National medical research center of neurosurgery of the Ministry of Health of the Russian Federation (BNC)
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12
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Spontaneous intracranial hypotension: searching for the CSF leak. Lancet Neurol 2022; 21:369-380. [DOI: 10.1016/s1474-4422(21)00423-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
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13
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Schievink WI, Maya MM, Moser F, Prasad R, Wadhwa V, Cruz R, Nuño M. Multiple Spinal CSF Leaks in Spontaneous Intracranial Hypotension: Do They Exist? Neurol Clin Pract 2021; 11:e691-e697. [PMID: 34840885 DOI: 10.1212/cpj.0000000000001084] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Objective To determine the frequency of multiple spinal CSF leaks in a recent group of patients with spontaneous intracranial hypotension (SIH) who were investigated with digital subtraction myelography (DSM). Methods This observational study was conducted using data from a prospectively maintained data base of patients who meet the International Classification of Headache Disorders, third edition, criteria for SIH. The patient population consisted of a consecutive group of 745 patients with SIH who underwent DSM between March 2009 and February 2020. Based on the results of DSM, participants were classified according to the type and number of spinal CSF leaks. Results Among 398 patients with SIH and extradural CSF on spinal imaging, multiplicity of CSF leaks was observed in none of 291 patients with type 1a ventral leaks and in 4 (6.2%) of 65 patients with type 1b (postero-) lateral leaks. Among 97 patients with SIH from spinal CSF-venous fistulas (type 3 leaks) who did not have extradural CSF on spinal imaging, 9 patients (9.3%) had multiple fistulas (p < 0.0001 for comparison between groups). Type 3 and type 1a or 1b CSF leaks coexisted in an additional 5 patients. Conclusions Among patients with SIH, multiplicity of CSF leaks was observed radiographically in none of the patients with ventral leaks, in 6% of patients with lateral leaks, and in 9% of patients with CSF-venous fistulas. These results suggest that patients with SIH can be reassured that the occurrence of multiple CSF leaks is negligible to uncommon at most, depending on the type of CSF leak.
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Affiliation(s)
- Wouter I Schievink
- Department of Neurosurgery (WIS, RBC) and Department of Imaging (MM, FGM, RSP, VSW), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Public Health Sciences (MN), University of California, Davis
| | - M Marcel Maya
- Department of Neurosurgery (WIS, RBC) and Department of Imaging (MM, FGM, RSP, VSW), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Public Health Sciences (MN), University of California, Davis
| | - Franklin Moser
- Department of Neurosurgery (WIS, RBC) and Department of Imaging (MM, FGM, RSP, VSW), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Public Health Sciences (MN), University of California, Davis
| | - Ravi Prasad
- Department of Neurosurgery (WIS, RBC) and Department of Imaging (MM, FGM, RSP, VSW), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Public Health Sciences (MN), University of California, Davis
| | - Vikram Wadhwa
- Department of Neurosurgery (WIS, RBC) and Department of Imaging (MM, FGM, RSP, VSW), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Public Health Sciences (MN), University of California, Davis
| | - Rachelle Cruz
- Department of Neurosurgery (WIS, RBC) and Department of Imaging (MM, FGM, RSP, VSW), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Public Health Sciences (MN), University of California, Davis
| | - Miriam Nuño
- Department of Neurosurgery (WIS, RBC) and Department of Imaging (MM, FGM, RSP, VSW), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Public Health Sciences (MN), University of California, Davis
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14
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Majeed K, Hanz SZ, Roytman M, Chazen JL, Greenfield JP. Identification and surgical ligation of spinal CSF-venous fistula. Surg Neurol Int 2021; 12:514. [PMID: 34754564 PMCID: PMC8571184 DOI: 10.25259/sni_539_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background: CSF-venous fistulas (CVF) may cause incapacitating positional headaches resulting from spontaneous intracranial hypotension/hypovolemia (SIH). Their etiology remains unknown, although unrecognized local trauma may precipitate SIH. In addition, they are diagnostically challenging despite various imaging tools available. Here, we present CVF identification using magnetic resonance myelography (MRM) and elaborate on their surgical management techniques. Methods: Retrospective charts of confirmed and treated CVF patients with attention to their diagnostic imaging modalities and management techniques were further reviewed. Results: Six cases were identified of which three are presented here. There were two females and one male patient. All had fistulas on the left side. Two were at T7-T8 while the third was at T9-T10 level. Two underwent hemilaminotomies at the T7-T8 while the third underwent a foraminotomy at T9 level to access the fistula site. All CVF were closed with a combination of an aneurysm clip and a silk tie. On follow-up, all had complete resolution of symptoms with no evidence of recurrence. Conclusion: Of the various imaging modalities available, MRM is particularly sensitive in localizing CVF spinal nerve level and their laterality. In addition, the technique of aneurysm clip ligation and placement of a silk tie is curative for these lesions.
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Affiliation(s)
- Kashif Majeed
- Department of Neurological Surgery Weill Cornell Medicine, New York City, New York, United States
| | - Samuel Z Hanz
- Department of Neurological Surgery Weill Cornell Medicine, New York City, New York, United States
| | - Michelle Roytman
- Department of Radiology, Division of Neuroradiology, Weill Cornell Medicine, New York City, New York, United States
| | - J Levi Chazen
- Department of Radiology, Division of Neuroradiology, Weill Cornell Medicine, New York City, New York, United States
| | - Jeffrey P Greenfield
- Department of Neurological Surgery Weill Cornell Medicine, New York City, New York, United States
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15
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Aljuboori Z, McGrath M, Essibayi MA, Zaidi S, Hallam D, Ghodke B. Spontaneous spinal cerebrospinal fluid venous-fistula treated with transvenous embolization: A case report. Surg Neurol Int 2021; 12:492. [PMID: 34754542 PMCID: PMC8571307 DOI: 10.25259/sni_878_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/04/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Spinal cerebrospinal fluid venous fistula (CVF) is a recognized cause of chronic positional headache and spontaneous intracranial hypotension (SIH). It occurs due to an aberrant connection formed between the spinal subarachnoid space and an adjacent spinal epidural vein. The diagnosis of CVF can be difficult to establish but can be documented utilizing advanced imaging techniques (e.g., enhanced MR myelography/digital subtraction myelography). Their treatment involves surgical ligation of the involved nerve root, imaging-guided epidural blood patching, and/or endovascular embolization. Here, we report a 40-year-old male who presented with a symptomatic lumbar CVF successfully treated with transvenous embolization. Case Description: A 40-year-old male presented with several months of positional headaches. The MRI of the brain showed diffuse pachymeningeal enhancement consistent with the diagnosis of SIH. Although the MR of the lumbar spine was unremarkable, the MR myelogram with digital subtraction imaging showed a CVF at the L2 level. Following transvenous embolization (i.e., through the Azygous vein), the patient’s symptoms fully resolved. Conclusion: Spinal CVF are rare and may cause chronic headaches and symptoms/signs of SIH. In this case, an MR myelogram with digital subtraction images demonstrated the anomalous connection between the spinal subarachnoid space and an adjacent spinal epidural vein at the L2 level. Although open surgical ablation of this connection may be feasible, less invasive techniques such as endovascular embolization should become the treatment of choice for the future management of CVF.
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Affiliation(s)
- Zaid Aljuboori
- Department of Neurosurgery, University of Washington, Seattle, Washington, United States
| | - Margaret McGrath
- Department of Neurosurgery, University of Washington, Seattle, Washington, United States
| | | | - Saif Zaidi
- Department of Medicine, University of Paris, Paris, France
| | - Danial Hallam
- Department of Radiology, Univ of Washington, Seattle, Washington, United States
| | - Basavaraj Ghodke
- Department of Radiology, Univ of Washington, Seattle, Washington, United States
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16
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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: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [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.
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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.
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17
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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: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [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.
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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.
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18
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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] [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.
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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
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19
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Shlobin NA, Shah VN, Chin CT, Dillon WP, Tan LA. Cerebrospinal Fluid-Venous Fistulas: A Systematic Review and Examination of Individual Patient Data. Neurosurgery 2021; 88:931-941. [PMID: 33438744 DOI: 10.1093/neuros/nyaa558] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/04/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is usually caused by a spinal cerebrospinal fluid (CSF) leak. CSF-venous fistula is an underdiagnosed cause of spinal CSF leak, as it is challenging to identify on myelography. OBJECTIVE To review existing literature to summarize common presentations, diagnostic imaging modalities, and current treatment strategies for CSF-venous fistulas. METHODS We conducted a systematic review using PubMed, Embase, Scopus, and Web of Science databases to identify studies discussing CSF-venous fistulas. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full. RESULTS Of 180 articles identified, 16 articles met inclusion criteria. Individual patient data was acquired from 7 studies reporting on 18 patients. CSF-venous fistula most frequently presented as positional headache. Digital subtraction myelography provided greatest detection of CSF-venous fistula in the lateral decubitus position and detected CSF-venous fistula in all individual patient cases. Dynamic computed tomography (CT) myelogram enabled detection and differentiation of CSF-venous fistulas from low-flow epidural leaks. The majority of fistulas were in the thoracic spine and slightly more common on the right. Epidural blood patch (EBP) provided temporary or no relief in all individual patients. Resolution or improvement of clinical symptoms and radiologic normalization were observed in all surgically treated patients. CONCLUSION Although rare, CSF-venous fistula is an important cause of spinal CSF leak contributing to SIH. Dynamic CT myelogram and digital subtraction myelography, particularly in the lateral decubitus position, are the most accurate and effective diagnostic imaging modalities. EBPs often provide only transient relief, while surgical management is preferred.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vinil N Shah
- Department of Radiology and Biomedical Imaging. University of California San Francisco, San Francisco, California
| | - Cynthia T Chin
- Department of Radiology and Biomedical Imaging. University of California San Francisco, San Francisco, California
| | - William P Dillon
- Department of Radiology and Biomedical Imaging. University of California San Francisco, San Francisco, California
| | - Lee A Tan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
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20
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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.
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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.
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21
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Schievink WI, Maya M, Prasad RS, Wadhwa VS, Cruz RB, Moser FG. Spinal CSF-Venous Fistulas in Morbidly and Super Obese Patients with Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2020; 42:397-401. [PMID: 33334852 DOI: 10.3174/ajnr.a6895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 09/15/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal CSF-venous fistulas are increasingly recognized as the cause of spontaneous intracranial hypotension. Here, we describe the challenges in the care of patients with CSF-venous fistulas who are morbidly or super obese. MATERIALS AND METHODS A review was undertaken of all patients with spontaneous intracranial hypotension and a body mass index of >40 who underwent digital subtraction myelography in the lateral decubitus position to look for CSF-venous fistulas. RESULTS Eight patients with spontaneous intracranial hypotension with a body mass index of >40 underwent lateral decubitus digital subtraction myelography. The mean age of these 5 women and 3 men was 53 years (range, 45 to 68 years). Six patients were morbidly obese (body mass indexes = 40.2, 40.6, 41, 41.8, 45.4, and 46.9), and 2 were super obese (body mass indexes = 53.7 and 56.3). Lumbar puncture showed an elevated opening pressure in 5 patients (26.5-47 cm H2O). The combination of an elevated opening pressure and normal conventional spine imaging findings resulted in a misdiagnosis (midbrain glioma and demyelinating disease, respectively) in 2 patients. Prior treatment included surgical nerve root ligation for suspected CSF-venous fistula in 3 patients. Digital subtraction myelography demonstrated a CSF-venous fistula in 6 patients (75%). Rebound high-pressure headache occurred in all 6 patients following surgical ligation of the fistula, and papilledema developed in 3. CONCLUSIONS In our series, opening pressure was generally elevated in patients with morbid or super obesity. The yield of identifying CSF-venous fistulas with digital subtraction myelography in this patient population can approach that of the nonobese patient population. These patients may be at higher risk of developing rebound high-pressure headaches and papilledema.
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Affiliation(s)
- W I Schievink
- From the Departments of Neurosurgery (W.I.S., R.B.C.)
| | - M Maya
- Imaging (M.M., R.S.P., V.S.W., F.G.M.), Cedars-Sinai Medical Center, Los Angeles, California
| | - R S Prasad
- Imaging (M.M., R.S.P., V.S.W., F.G.M.), Cedars-Sinai Medical Center, Los Angeles, California
| | - V S Wadhwa
- Imaging (M.M., R.S.P., V.S.W., F.G.M.), Cedars-Sinai Medical Center, Los Angeles, California
| | - R B Cruz
- From the Departments of Neurosurgery (W.I.S., R.B.C.)
| | - F G Moser
- Imaging (M.M., R.S.P., V.S.W., F.G.M.), Cedars-Sinai Medical Center, Los Angeles, California
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22
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Mamlouk MD, Ochi RP, Jun P, Shen PY. Decubitus CT Myelography for CSF-Venous Fistulas: A Procedural Approach. AJNR Am J Neuroradiol 2020; 42:32-36. [PMID: 33122215 DOI: 10.3174/ajnr.a6844] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/12/2020] [Indexed: 11/07/2022]
Abstract
Decubitus CT myelography is a reported method to identify CSF-venous fistulas in patients with spontaneous intracranial hypotension. One of the main advantages of decubitus CT myelography in detecting CSF-venous fistulas is using gravity to dependently opacify the CSF-venous fistula, which can be missed on traditional myelographic techniques. Most of the CSF-venous fistulas in the literature have been identified in patients receiving general anesthesia and digital subtraction myelography, a technique that is not performed at all institutions. In this article, we discuss the decubitus CT myelography technique and how to implement it in daily practice.
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Affiliation(s)
- M D Mamlouk
- From the Department of Radiology (M.D.M., P.J., P.Y.S.), 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
| | - R P Ochi
- Department of Radiology (R.P.O.), The Permanente Medical Group, Kaiser Permanente Medical Center, Sacramento, Sacramento, California
| | - P Jun
- From the Department of Radiology (M.D.M., P.J., P.Y.S.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - P Y Shen
- From the Department of Radiology (M.D.M., P.J., P.Y.S.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
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