The utility of radioisotope cisternography in low CSF/volume syndromes compared to myelography

Objective The objective of this report is to compare computed tomography (CT) and magnetic resonance (MR) myelography with radioisotope cisternography (RC) for detection of spinal cerebrospinal (CSF) leaks. Methods We retrospectively reviewed 12 spontaneous intracranial hypotension (SIH) patients; CT and RC were performed simultaneously. Three patients had MR myelography. Results CT and/or MR myelography identified CSF leaks in four of 12 patients. RC detected spinal leaks in all three patients confirmed by CT myelography; RC identified the CSF leak location in two of three cases, and these were due to osteophytic spicules and/or discs. RC showed only enlarged perineural activity. Only intrathecal gadolinium MR myelography clearly identified a slow leak from a perineural cyst. In eight remaining cases, the leak site was unknown; however, two of these showed indirect signs of CSF leak on RC. CSF slow leaks from perineural cysts were the most common presumed etiology; and the cysts were best visualized on myelography. Conclusion RC is comparable to CT myelography but has spatial limitations and should be limited to atypical cases.

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Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

Journal of Neurosurgery ◽

10.3171/jns.1996.84.4.0598 ◽

1996 ◽

Vol 84 (4) ◽

pp. 598-605 ◽

Cited By ~ 238

Author(s):

Wouter I. Schievink ◽

Fredric B. Meyer ◽

John L. D. Atkinson ◽

Bahram Mokri

Keyword(s):

Cerebrospinal Fluid ◽

Thoracic Spine ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Csf Leak ◽

Cervicothoracic Junction ◽

Ct Myelography ◽

Content Type ◽

Fine Print ◽

Csf Leaks

✓ Spinal cerebrospinal fluid (CSF) leaks are often implicated as the cause of the syndrome of spontaneous intracranial hypotension, but they have rarely been demonstrated radiographically or surgically. The authors reviewed their experience with documented cases of spinal CSF leaks of spontaneous onset in 11 patients including their surgical observations in four of the patients. The mean age of the six women and five men included in the study was 38 years (range 22–51 years). All patients presented with a postural headache; however, most had additional symptoms, including nausea, emesis, sixth cranial-nerve paresis, or local back pain at the level of the CSF leak. All patients underwent indium-111 radionucleotide cisternography or computerized tomographic (CT) myelography. The location of the spontaneous CSF leak was in the cervical spine in two patients, the cervicothoracic junction in three patients, the thoracic spine in five patients, and the lumbar spine in one patient. The false negative rate for radionucleotide cisternography was high (30%). Subdural fluid collections, meningeal enhancement, and downward displacement of the cerebellum, resembling a Chiari I malformation, were commonly found on cranial imaging studies. In most patients, the symptoms resolved in response to supportive measures or an epidural blood patch. Leaking meningeal diverticula were found to be the cause of the CSF leak in four patients who underwent surgery. In three patients these diverticula could be ligated with good result but in one patient an extensive complex of meningeal diverticula was found to be inoperable. Two patients had an unusual body habitus and joint hypermobility, and two other patients had suffered a spontaneous retinal detachment at a young age. In conclusion, spontaneous spinal CSF leaks are uncommon, but they are increasingly recognized as a cause of spontaneous intracranial hypotension. Most spinal CSF leaks are located at the cervicothoracic junction or in the thoracic spine, and they may be associated with meningeal diverticula. The radiographic study of choice is CT myelography. The disease is usually self-limiting, but in selected cases our experience with surgical ligation of leaking meningeal diverticula has been satisfactory. An underlying connective tissue disorder may be present in some patients with a spontaneous spinal CSF leak.

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Vanishing calcification associated with a spontaneous ventral spinal cerebrospinal fluid leak

Cephalalgia ◽

10.1177/0333102416628468 ◽

2016 ◽

Vol 36 (14) ◽

pp. 1366-1369 ◽

Cited By ~ 2

Author(s):

Wouter I Schievink ◽

Lindsey Ross ◽

Ravi S Prasad ◽

M Marcel Maya

Keyword(s):

Magnetic Resonance Imaging ◽

Cerebrospinal Fluid ◽

Magnetic Resonance ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Csf Leak ◽

Uneventful Recovery ◽

Resonance Imaging ◽

Computed Tomographic Myelography ◽

Csf Leaks

Background Some patients with spontaneous intracranial hypotension have a ventral spinal cerebrospinal fluid (CSF) leak and these CSF leaks may be associated with calcified disk herniations. Identifying these calcifications is helpful in directing treatment. We report here the unusual case of a patient with a ventral CSF leak in whom the associated calcification absorbed over a five-month period. Case report A 42-year-old woman developed orthostatic headaches and bilateral abducens nerve palsies. Magnetic resonance imaging of her brain showed typical findings of spontaneous intracranial hypotension. Magnetic resonance imaging of her spine showed an extensive cervicothoracic CSF leak. Computed tomographic myelography showed calcification at the Th1–2 disk space. Three epidural blood patches were performed, but her symptoms persisted. Digital subtraction myelography performed five months later showed an upper thoracic ventral CSF, but the calcification was no longer present. A dural tear, found at surgery at the Th1–2 level, was repaired and the patient made an uneventful recovery. Discussion The resorption of calcifications at the level of a ventral spinal CSF leak could explain the absence of any calcifications in at least some patients with such leaks and demonstrates the usefulness of reviewing previous imaging in patients with ventral CSF leaks if the exact site of the leak remains unknown.

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Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography

Journal of Neurosurgery ◽

10.3171/jns.2000.92.5.0873 ◽

2000 ◽

Vol 92 (5) ◽

pp. 873-876 ◽

Cited By ~ 45

Author(s):

Akira Matsumura ◽

Izumi Anno ◽

Hiroshi Kimura ◽

Eiichi Ishikawa ◽

Tadao Nose

Keyword(s):

Magnetic Resonance ◽

Intracranial Hypotension ◽

Direct Evidence ◽

Spontaneous Intracranial Hypotension ◽

Content Type ◽

Highly Sensitive ◽

Csf Leakage ◽

Leakage Site ◽

A Site ◽

Mr Myelography

✓ The authors describe a case of spontaneous intracranial hypotension in which the leakage site was determined by using magnetic resonance (MR) myelography. This technique demonstrated the route of cerebrospinal fluid (CSF) leakage, whereas other methods failed to show direct evidence of leakage. Magnetic resonance myelography is a noninvasive method that is highly sensitive in detecting CSF leakage. This is the first report in which a site of CSF leakage was detected using MR myelography.

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Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

Journal of Neurosurgery ◽

10.3171/2011.12.jns111474 ◽

2012 ◽

Vol 116 (4) ◽

pp. 749-754 ◽

Cited By ~ 32

Author(s):

Wouter I. Schievink ◽

Marc S. Schwartz ◽

M. Marcel Maya ◽

Franklin G. Moser ◽

Todd D. Rozen

Keyword(s):

Skull Base ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Spinal Imaging ◽

Radiological Data ◽

Single Instance ◽

Csf Leakage ◽

Csf Leaks

Object Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. Methods Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period. Results Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. Conclusions There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

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Spontaneous Intracranial Hypotension: Recommendations for Management

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100013664 ◽

2013 ◽

Vol 40 (2) ◽

pp. 144-157 ◽

Cited By ~ 24

Author(s):

Farnaz Amoozegar ◽

Darryl Guglielmin ◽

William Hu ◽

Denise Chan ◽

Werner J. Becker

Keyword(s):

Computed Tomography ◽

Clinical Trials ◽

Mr Imaging ◽

Intracranial Hypotension ◽

Literature Search ◽

Spontaneous Intracranial Hypotension ◽

Normal Brain ◽

Non Invasive ◽

Radionuclide Cisternography ◽

Mr Myelography

A literature search found no clinical trials or guidelines addressing the management of spontaneous intracranial hypotension (SIH). Based on the available literature and expert opinion, we have developed recommendations for the diagnosis and management of SIH. For typical cases, we recommend brain magnetic resonance (MR) imaging with gadolinium to confirm the diagnosis, and conservative measures for up to two weeks. If the patient remains symptomatic, up to three non-directed lumbar epidural blood patches (EBPs) should be considered. If these are unsuccessful, non-invasive MR myelography, radionuclide cisternography, MR myelography with intrathecal gadolinium, or computed tomography with myelography should be used to localize the leak. If the leak is localized, directed EPBs should be considered, followed by fibrin sealant or neurosurgery if necessary. Clinically atypical cases with normal brain MR imaging should be investigated to localize the leak. Directed EBPs can be used if the leak is localized; non-directed EBPs should be used only if there are indirect signs of SIH.

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Intracranial Hypotension for Anesthesiologists: What We Should Know

Pain Management Case Reports ◽

10.36076/pmcr.2019/3/69 ◽

2019 ◽

pp. 69-76

Author(s):

Maria Eugenia Calvo

Keyword(s):

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Case Series ◽

Low Flow ◽

Csf Leak ◽

Common Denominator ◽

Invasive Treatment ◽

Blood Patch ◽

Mechanism Of Trauma ◽

Csf Leaks

The common denominator of spontaneous intracranial hypotension (SIH), postsurgical cerebral spinal fluid (CSF) leaks, and postpuncture headache (PPH) is a decrease in CSF volume. The typical presentation is orthostatic headaches, but atypical headaches can be difficult to diagnose and challenging to treat. Management is based on clinical suspicion and characterization of the headache, followed by imaging (noninvasive or invasive). Treatment ranges from conservative to different modalities of epidural blood patches, fibrin glue injections, or surgical exploration and repair. We report 5 cases with great variation in clinical and radiological presentations. Two cases of SIH involved difficult diagnosis and treatment, 2 others featured postsurgical high-flow CSF leaks, and one case presented with a low-flow CSF leak that needed closer evaluation in relation to hardware manipulation. In all cases, recommendations for diagnosis and management of intracranial hypotension were followed, even though in 3 cases the mechanism of trauma was not related to spontaneous hypotension. All cases of headache were resolved. The actual recommendations for SIH are very effective for PPH and postsurgical CSF leaks. With this case series, we illustrate how anatomical and clinical considerations are paramount in choosing appropriate imaging modalities and clinical management. Key words: CSF leak, epidural blood patch, intracranial hypotension, postural headaches, subdural hematomas

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