Digital subtraction myelography for the identification of spontaneous spinal CSF-venous fistulas

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>In most patients with spontaneous intracranial hypotension, a spinal CSF leak can be found, but occasionally, no leak can be demonstrated despite extensive spinal imaging. Failure to localize a CSF leak limits treatment options. The authors recently reported the discovery of CSF-venous fistulas in patients with spontaneous intracranial hypotension and now report on the use of digital subtraction myelography in patients with spontaneous intracranial hypotension but no CSF leak identifiable on conventional spinal imaging (i.e., non–digital subtraction myelography).</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The patient population consisted of 53 consecutive patients with spontaneous intracranial hypotension who underwent digital subtraction myelography but in whom no spinal CSF leak (i.e., presence of extradural CSF) was identifiable on conventional spinal imaging.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The mean age of the 33 women and 20 men was 53.4 years (range 29–71 years). A CSF-venous fistula was demonstrated in 10 (19%) of the 53 patients. A CSF-venous fistula was found in 9 (27%) of the 33 women and in 1 (5%) of the 20 men (p = 0.0697). One patient was treated successfully with percutaneous injection of fibrin sealant. Nine patients underwent surgery for the fistula. Surgery resulted in complete resolution of symptoms in 8 patients (follow-up 7–25 months), and in 1 patient, symptoms recurred after 4 months.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>In this study, the authors found a CSF-venous fistula in approximately one-fifth of the patients with recalcitrant spontaneous intracranial hypotension but no CSF leak identifiable on conventional spinal imaging. The authors suggest that digital subtraction myelography be considered in this patient population.</jats:p></jats:sec>

Prevalence of hyperdense paraspinal vein sign in patients with spontaneous intracranial hypotension without dural CSF leak on standard CT myelography

“…The thoracic location (4-7) and female predominance (4, 5, 7) of the hyperdense paraspinal vein is in keeping with others' results of reported CVF (4,5,7). When including our 7 cases strongly suggestive of CVF and the other 19 published cases, all have occurred at thoracic levels, 69% (18 of 26) on the right, and 69% (18 of 26) in females.…”

“…CVF first appeared in the literature in 2014 (4), and is thus at present still an underrecognized cause of SIH. The clinical results of the small number of reported surgically confirmed cases suggest that most patients with CVF (17 of 18 with available follow-up) can respond successfully to treatment, typically surgical obliteration or nerve root ligation (4,5,7). This implies that making a diagnosis of CVF has important therapeutic implications.…”

Spontaneous Intracranial Hypotension: A Systematic Imaging Approach for CSF Leak Localization and Management Based on MRI and Digital Subtraction Myelography

“…CT-guided focal fibrin patching may have some success in the hands of other authors; however, in our experience, it has not provided a durable cure. Surgical ligation of a CVF as described by Schievink et al, 5,22 in our experience, is the most efficacious treatment of these lesions.…”

Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions

“…Ventral dural tears are a major source of spontaneous CSF leaks, and are often associated with calcified thoracic disk herniations or osteophytes. 39,40 This leak type has been increasingly identified over the past few years. 36 Another recently identified cause of SIH is the CSF-venous fistula.…”

“…Because the leak is not into the epidural space, they may be occult on spinal imaging, although specialized type of myelography may show the fistula. 39,40 This leak type has been increasingly identified over the past few years.…”