MRI myelography for diagnosis and targeted blood patching of multilevel thoracic spine CSF leaks: Report of 2 cases

Abstract

In patients with occult cerebrospinal fluid (CSF) leaks or CSF leak syndrome, orthostatic headaches are a common presenting symptom. Although computed tomography (CT) myelography has historically been the gold standard for diagnosis with radioisotope cisternography as a diagnostic alternative, magnetic resonance imaging (MRI) myelography using intrathecal gadolinium has reported sensitivity of 80%-87%. Two patients with spontaneous orthostatic headaches lasting for several days were diagnosed with CSF leaks at multiple thoracic segments using MRI myelogram with intrathecal gadolinium (Gadavist, Bayer, Whippany, NJ). This allowed for subsequent targeted treatment with CT fluoroscopy guidance, resulting in therapeutic responses within 1-2 treatment with targeted blood patching. Although intrathecal gadolinium is an off-label use, the superior contrast resolution and lack of radiation exposure makes MRI myelography an excellent imaging modality for diagnosing CSF leak, targeting treatment, and monitoring outcomes compared to CT myelography and radioisotope cisternography.

T2-Sampling Perfection With Application-Optimized Contrasts by Using Flip Angle Evolution (SPACE) Protocol MRI: A Safe, Minimally Invasive Screening Tool for Spinal CSF Leak Causing Spontaneous Intracranial Hypotension

“…While spontaneous intracranial hypotension (SIH) is an uncommon cause of intractable headache [ 1 , 2 ] it is commonly encountered due to a spinal cerebrospinal fluid (CSF) leak [ 1 ]. Spontaneous intracranial hypotension is associated with not only severe head pain but also other multiple disabling symptoms and findings including cognitive dysfunction, behavior changes, vision changes, diplopia, and many more [ 3 ].…”

“…Recognizing this entity requires clinical skills, but even in the presence of excellent history and physical examination, the diagnosis may get delayed because of the lack of a reasonable screening test. Current testing is either overly invasive namely CSF infusion protocols or both invasive and insensitive such as a lumbar puncture (LP) with an opening pressure (OP) or computed tomography myelogram (CTM) [ 2 ]. The later two procedures are commonly employed in the diagnostic workup and require access to thecal space; they unfortunately lack sensitivity.…”

“…The later two procedures are commonly employed in the diagnostic workup and require access to thecal space; they unfortunately lack sensitivity. Computed tomography myelogram will not identify a leak if it is intermittent or very slow and in the setting of a spinal CSF leak the opening pressure on LP may be high, low, or normal [ 2 ]. Recent studies concluded that the T2-sampling perfection with application-optimized contrasts by using flip angle evolution (SPACE) is superior to the T2 fast spin echo (FSE) MR imaging for visualizing the cervical spine as it has fewer CSF flow/pulsation artifacts the latter of which ameliorate visibility [ 4 ].…”