Role of Conventional Dynamic Myelography for Detection of High-Flow Cerebrospinal Fluid Leaks

Abstract

Background Spinal imaging is essential to identify and localize cerebrospinal fluid (CSF) leaks in spontaneous intracranial hypotension (SIH) patients when targeted treatment is necessary. Purpose Provide an in-depth presentation of the conventional dynamic myelography (CDM) technique for localizing spinal CSF leaks in SIH patients. Material and Methods Consecutive SIH patients with a CSF leak confirmed on CDM and postmyelography computed tomography (CT) investigated at our institution between 2013 and 2019 were retrospectively analyzed. Intraoperative reports were reviewed to confirm the accuracy of CDM. Results In total, 62 patients (mean age 45 years) were included; 48 with a ventral dural tear, 12 with a meningeal diverticulum, and in 2 patients positive for spinal longitudinal extradural CSF collection the site remained unclear. The leak was identified during the first and the second CDM in 43 and 17 patients, respectively. The use of CDM correctly identified the site of the CSF leak in all but one patient undergoing surgical closure (45/46, 98%). The mean fluoroscopy time was 7.8 min (range 1.8-14.4 min) with a radiation dose for a single examination of 310 mGy (range 28-1237 mGy). ConclusionThe CDM procedure has a high accuracy for spinal CSF leak localization including dural tears and spinal nerve diverticula. It is the technique with the highest temporal resolution, is robust to breathing artifacts, allows great flexibility regarding patient positioning, compares favorably to other dynamic examinations with respect to the radiation dose and does not require general anesthesia. For CSF venous fistulas, however, other dynamic examinations, such as digital subtraction myelography, seem more appropriate. Keywords Spontaneous intracranial hypotension • CSF leak • Conventional dynamic myelographyAvailability of data and material The datasets analyzed during the current study are not publicly available owing to preclusion from dissemination under Swiss Federal Law regulations; however, they are available from the corresponding author on reasonable request. Where not in conflict with constraints of the original ethical approval under which the data were collected, pseudoanonymized data will be made available for appropriate collaborative research, subject to appropriate ethical approval being gained for such use.

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

“…In the setting of probable CSF pooling seen on a T2-SPACE protocol MRI, it would seem reasonable to proceed with the more specific testing viz. DSM or dynamic computed tomography myelography (DCTM) post-MRI [ 7 ]. This approach should help decrease the latency from disease onset to diagnosis as it is more likely to be ordered in the setting of lesser suspicion than perhaps is required for a physician to justify an invasive CT myelogram.…”

Outcome after surgical treatment of cerebrospinal fluid leaks in spontaneous intracranial hypotension—a matter of time

“…Our preoperative standardized diagnostic workup was performed as described previously [ 12 , 13 ]. Spinal imaging consisted of a stepwise protocol using more invasive imaging techniques with increasing suspicion of a spinal CSF leak to ultimately localize the exact site of leakage [ 12 , 14 , 15 ]. If no spinal CSF leak was identified despite clear signs of SIH, a CSF-venous fistula was searched by dynamic CT-myelography or digital substraction myelography.…”

Spontaneous intracranial hypotension: diagnostic and therapeutic workup

“…Next step is dynamic (digital subtraction) myelography. The patient lies in prone position; the head of the table is tilted down, while lateral fluoroscopic or digital subtraction images are acquired during gentle intrathecal contrast injections [25]. The goal is to locate the ventral dural tear by exactly locating the point of egress of iodinated contrast medium into the epidural space.…”

“…The goal is to locate the ventral dural tear by exactly locating the point of egress of iodinated contrast medium into the epidural space. This is achieved with the iodinated contrast medium slowing flowing into a caudo-cranial direction on the ventral side of the subarachnoid space [25][26][27] (Fig. 2).…”