Decubitus CT Myelography for CSF-Venous Fistulas: A Procedural Approach

Mamlouk, Mark D.; Ochi, Robert P.; Jun, Peter; Shen, Peter Y.

doi:10.3174/ajnr.a6844

Cited by 56 publications

(32 citation statements)

References 17 publications

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“…Lateral decubitus DSM is our first test of choice in these patients [5]. Other institutions currently use decubitus CTM as their first test of choice to localize CVFs [12,13]; however, recent studies have shown that GdM can also detect CVFs and have questioned whether it may have value in these patients [8]. We found that the yield of GdM in patients without SLECs is approximately 10% for localizing CVFs.…”

Section: Discussionmentioning

confidence: 77%

Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization

et al. 2021

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Purpose Intrathecal gadolinium magnetic resonance (MR) myelography can be used to localize various types of spinal cerebrospinal fluid (CSF) leaks; however, its diagnostic yield is not well known. We sought to determine the diagnostic yield of MR myelography in patients with spontaneous intracranial hypotension. Methods A retrospective review was performed on all patients who had undergone intrathecal gadolinium MR myelography at our institution from 2002 to 2020 for suspected spinal CSF leak. The MR myelography images were reviewed for the presence or absence of a spinal CSF leak site. Images were also evaluated for the presence an extradural fluid collection. Results A total of 97 patients were included in the final cohort. The average age was 52.6 years; 67.0% were female, 4 patients underwent 2 examinations each, yielding a total of 101 MR myelograms. The source of a spinal CSF leak was localized in 14 patients. The diagnostic yield for CSF leak localization on intrathecal gadolinium MR myelography was 14/101 (13.9%) per GdM examination and 14/97 (14.4%) per patient. Among the subset of patients without extradural fluid collections, the yield was 15.7% per examination. All detected leaks were either CSF-venous fistulas or distal nerve root sleeve tears. Conclusion Intrathecal gadolinium MR myelography is capable of localizing CSF-venous fistulas and distal nerve root sleeve tears; however, our data show that it has a limited diagnostic yield. We suggest that other modalities may be a better first step before attempting intrathecal gadolinium MR myelography.

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Section: Discussionmentioning

confidence: 77%

Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization

et al. 2021

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“…This increased contrast concentration was deemed likely a primary factor in increasing the visibility of the CVFs, but there also appeared to be an effect of gravity that was independent of the concentration of contrast. The diagnostic yield of decubitus CTM for CVF detection was found to be 50% in patients with SIH who had no epidural fluid collection seen on spine MRI [8].…”

Section: Cross-sectional Techniquesmentioning

confidence: 95%

“…The lower thoracic levels between T7 and T12 are the most common locations, although upper thoracic CVFs are frequently encountered as well [4][5][6][7]. Fistulas in the upper lumbar or lower cervical levels are less common but have also been reported [4,5,8].…”

Section: Accepted Manuscriptmentioning

confidence: 99%

“…Various case series have reported discrepant results as to whether the right or left side of the spine is more commonly involved, suggesting that if a predilection for laterality exists, it is not a strong one [4,7,8]. Unlike dural tears (the first described cause of intracranial hypotension), most CVFs do not result in pooling of CSF in the epidural space.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

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CSF–Venous Fistulas: Anatomy and Diagnostic Imaging

Kranz

Gray

Malinzak

et al. 2021

American Journal of Roentgenology

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The publication of this Accepted Manuscript is provided to give early visibility to the contents of the article, which will undergo additional copyediting, typesetting, and review before it is published in its final form. During the production process, errors may be discovered that could affect the content of the Accepted Manuscript. All legal disclaimers that apply to the journal pertain. The reader is cautioned to consult the definitive version of record before relying on the contents of this document.

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“…This creates a pressure gradient driving blood from the inferior vena cava to the right atrium, increasing venous return to the heart. This blood flow also results in decreased intravascular pressure within the inferior vena cava, which would produce a gradient of pressure between the higher pressure CSF and the lower pressure epidural venous plexus and paraspinal veins [30][31][32][33]. CSF-venous fistulas can have a paravertebral (45%), lateral along the neural foramen (23%), or central drainage towards the epidural plexus (32%).…”

Section: Spine Mrimentioning

confidence: 99%

Spontaneous intracranial hypotension: diagnostic and therapeutic workup

et al. 2021

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Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with typical MRI findings among which engorgement of the venous sinuses, pachymeningeal enhancement, and effacement of the suprasellar cistern have the highest diagnostic sensitivity. SIH is in almost all cases caused by spinal CSF leaks. Spinal MRI scans showing so-called spinal longitudinal extradural fluid (SLEC) are suggestive of ventral dural tears (type 1 leak) which are located with prone dynamic (digital subtraction) myelography. As around half of the ventral dural tears are located in the upper thoracic spine, additional prone dynamic CT myelography is often needed. Leaking nerve root sleeves typically associated with meningeal diverticulae (type 2 leaks) and CSF-venous fistulas (type 3 leaks) are proven via lateral decubitus dynamic digital subtraction or CT myelography: type 2 leaks are SLEC-positive if the tear is proximal and SLEC-negative if it is distal, and type 3 leaks are always SLEC-negative. Although 30–70% of SIH patients show marked improvement following epidural blood patches applied via various techniques definite cure mostly requires surgical closure of ventral dural tears and surgical ligations of leaking nerve root sleeves associated with meningeal diverticulae or CSF-venous fistulas. For the latter, transvenous embolization with liquid embolic agents via the azygos vein system is a novel and valuable therapeutic alternative.

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Decubitus CT Myelography for CSF-Venous Fistulas: A Procedural Approach

Cited by 56 publications

References 17 publications

Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization

Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization

CSF–Venous Fistulas: Anatomy and Diagnostic Imaging

Spontaneous intracranial hypotension: diagnostic and therapeutic workup

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