Lateral decubitus dynamic CT myelography for fast cerebrospinal fluid leak localization

Madhavan, Ajay A; Verdoorn, Jared T.; Shlapak, Darya P.; Pope, Matthew C.; Benson, John C.; Diehn, Felix E.; Liebo, Greta B.; Lehman, Vance T.; Kim, Dong Kun; Oien, Michael P; Cutsforth‐Gregory, Jeremy K.; Carr, Carrie M.

doi:10.1007/s00234-022-02985-y

Cited by 13 publications

(4 citation statements)

References 12 publications

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“… 22 In brief, if the MRI spine demonstrated an epidural fluid collection, the patient was placed in the prone or decubitus position with hips elevated to evaluate for a ventral or lateral dural defect, respectively. 23 , 24 If the MRI spine did not demonstrate an epidural fluid collection, patients were placed in the lateral decubitus position on a HoverMatt inflatable device (Hovermatt Air Transfer System, Hovertech International) to evaluate for a CVF. Access to the thecal sac was obtained using a 22-gauge Whitaker spinal needle.…”

Section: Methodsmentioning

confidence: 99%

Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

et al. 2023

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Background and Objectives:Existing tools to diagnose spontaneous intracranial hypotension (SIH), namely spinal opening pressure (OP) and brain MRI, have limited sensitivity. We investigated whether evaluation of brain MRI using the Bern Score, combined with calculated craniospinal elastance, would aid in diagnosing SIH and provide insight into its pathophysiology.Methods:A retrospective chart review was performed of patients who underwent brain MRI and pressure-augmented dynamic CT myelography (dCTM) for suspicion of SIH. Two blinded Neuroradiologists assigned Bern Scores for each brain MRI. OP and incremental pressure changes after intrathecal saline infusion were recorded to calculate craniospinal elastance. The relationship between Bern Score, OP, elastance, and whether a leak was found were analyzed.Results:72 consecutive dCTMs were performed in 53 patients. 12 CSF-venous fistulae, two ruptured meningeal diverticula, two dural defects, and one dural bleb were found (17/53=32%). Among patients with imaging proven CSF leak/fistula, OP was normal in all but one patient, and was not significantly different in those with a leak compared to those without (15.1 vs 13.6 cm H2O, p = 0.24, A=0.40). Average Bern Score in individuals with a leak was significantly higher than in those without (5.35 vs 1.85, p < 0.001, A=0.85), even when excluding pachymeningeal enhancement from the score (3.77 vs 1.57, p = 0.001, A=0.78). Average elastance in those with a leak was higher than in those without, but this difference was not statistically significant (2.05 vs 1.20 mL/cm H2O, p = 0.19, A=0.40). Increased elastance was significantly associated with an increased Bern Score (p < 0.01, 95% CI -0.55, 0.12), and was significantly associated with venous distention, pachymeningeal enhancement, prepontine narrowing, and subdural collections, but not a narrowed mamillopontine or suprasellar distance.Discussion:OP is not an effective predictor for diagnosing CSF leak, and if used in isolation would result in misdiagnosis of 94% of patients in our cohort. The Bern Score was associated with a higher diagnostic yield of dCTM. Elastance was significantly associated with certain components of the Bern Score.

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Section: Methodsmentioning

confidence: 99%

Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

et al. 2023

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“…One report describes decubitus dynamic CTM for lateral leaks with 6 acquisitions of the spine. 12 Our modified technique was able to reduce the number of scan acquisitions and area of contrast (Fig 4). Last, owing to the rarity of these leaks, one may misinterpret the extradural collection on the spine MR imaging and position the patient in a Trendelenburg prone position and fail to identify the ruptured meningeal diverticulum.…”

Section: Discussionmentioning

confidence: 99%

Modified Dynamic CT Myelography for Type 1 and 2 CSF Leaks: A Procedural Approach

Mamlouk

Shen

Dahlin

2023

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Dynamic CT myelography can identify spinal CSF leaks secondary to dural tears (type 1) and ruptured meningeal diverticula (type 2), but the radiation can be high secondary to multiple successive acquisitions. The purpose of this article is to discuss the procedural approach of a modified dynamic CT myelography technique with single scan acquisitions, reduced contrast volume, and condensed scan coverage and compare its radiation dose with that in traditional dynamic CT myelography.

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“…This myelogram should be performed in the prone or decubitus position depending on the predominant location of the extradural fluid collection. [13][14][15] For conventional and digital subtraction myelograms, post-myelogram CT is usually also performed, which can identify underlying osseous lesions responsible for the leak that may inform surgical planning. A second round of dynamic myelography, preferably using dynamic CT myelography, is justified if post-myelography CT shows contrast in the epidural space but no localizable leak found on the first attempt of dynamic myelography.…”

Section: Diagnosis Of Sih and Identification Of Csfvfmentioning

confidence: 99%

“…Because spine MRI without intrathecal contrast cannot reliably localize CSF leaks, patients must undergo dynamic myelography with conventional dynamic myelography, digital subtraction myelography, or dynamic CT myelography to identify the exact location of the leak and allow targeted intervention. This myelogram should be performed in the prone or decubitus position depending on the predominant location of the extradural fluid collection 13–15. For conventional and digital subtraction myelograms, post-myelogram CT is usually also performed, which can identify underlying osseous lesions responsible for the leak that may inform surgical planning.…”

Section: Diagnosis Of Sih and Identification Of Csfvfmentioning

confidence: 99%

Transvenous Embolization of Cerebrospinal Fluid-Venous Fistulas: Pearls, Pitfalls, and Lessons Learned

Naylor,

Madhavan,

Cutsforth-Gregory

et al. 2023

Contemporary Neurosurgery

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Cerebrospinal fluid-venous fistulas (CSFVFs) are increasingly recognized as a cause of spontaneous intracranial hypotension (SIH), a debilitating neurologic condition that may present with postural headaches, hearing loss, and/or cognitive impairment. Curative treatment is available for patients whose fistulas are localized with myelography. Transvenous endovascular embolization has emerged in recent years as a safe, effective, and durable treatment option for patients with CSFVF. Here, we briefly review the clinical presentation of SIH, present diagnostic algorithm by which CSFVFs are identified, and discuss a stepwise treatment paradigm. We then detail endovascular treatment strategies of CSFVF with particular emphasis on direct versus indirect approaches to the fistula, embolization principles, and techniques to minimize complications. With increasing awareness of SIH and enhanced detection of CSFVF, it is important for endovascular neurosurgeons and neurointerventionalists to be familiar with transvenous CSFVF embolization strategies to meet the needs of this patient population.

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Lateral decubitus dynamic CT myelography for fast cerebrospinal fluid leak localization

Cited by 13 publications

References 12 publications

Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

Modified Dynamic CT Myelography for Type 1 and 2 CSF Leaks: A Procedural Approach

Transvenous Embolization of Cerebrospinal Fluid-Venous Fistulas: Pearls, Pitfalls, and Lessons Learned

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