Intrathecal preservative-free normal saline challenge magnetic resonance myelography for the identification of cerebrospinal fluid leaks in spontaneous intracranial hypotension

Abstract

S pontaneouS intracranial hypotension (SIH) classically presents as a positional headache that is worsened by orthostasis. Additional symptoms may include dizziness, tinnitus, vomiting, altered mental status, and behavioral changes. 10,11,16 Findings on routine brain CT and MRI scans help to confirm a clinical suspicion of SIH. 5These diagnostic imaging findings include pachymeningeal enhancement, a sagging brain, small ventricular size, and engorged venous sinuses. 9 The combination of these clinical and imaging findings makes diagnosing an SIH often straightforward.6 However, locating the causative CSF leak often remains a challenge. Although new therapeutic techniques have improved the rates of successful treatments of SIH patients with an occult leakage site, identifying the exact location of the CSF leak is preferred before deciding on therapy.11,15 The purpose of this case series was to present our experience with intrathecal preservative-free normal saline challenge followed by contrast-enhanced MR myelography (CEMRM), which we used to provoke and detect a CSF leak in patients with SIH.abbreviatioNs CEMRM = contrast-enhanced MR myelography; CTM = CT myelography; Gd = gadolinium; SIH = spontaneous intracranial hypotension. submitted September 5, 2014. accepted December 11, 2014. iNclude wheN citiNg Published online July 3, 2015; DOI: 10.3171/2014.12.JNS142057. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. The purpose of this case series was to describe the authors' experience with intrathecal preservative-free normal saline challenge coupled with contrast-enhanced MR myelography (CEMRM), which was used to provoke and detect a CSF leakage site in patients with SIH. methods The authors performed a retrospective review of the records of patients who underwent preservative-free normal saline challenge followed by intrathecal gadolinium (Gd) contrast infusion and MR myelography from 2010 to 2012. results The records survey identified 5 patients who underwent 6 procedures. Intrathecal preservative-free normal saline challenge followed by CEMRM identified a CSF leak during 5 of the 6 procedures. Previous CT myelograms were available from 4 patients, which did not reveal a leakage site. A CT myelogram of 1 patient showed a single leak, but the authors' saline challenge-CEMRM technique identified multiple additional leakage sites. Three patients exhibited transient postprocedural symptoms related to the saline infusion, but no long-term or permanent adverse effects related to the procedure were observed. coNclusioNs Instillation of preservative-free normal saline into the thecal sac followed by intrathecal Gd infusion is a safe technique that may increase the detection of a CSF leak on MR myelography images in patients with SIH.

Safety of Consecutive Bilateral Decubitus Digital Subtraction Myelography in Patients with Spontaneous Intracranial Hypotension and Occult CSF Leak

“…Contrast volumes were relatively constant but were included in the mean injectate calculations because they did constitute a large component of the total injectate volume. Griauzde et al 22 also reported transient neurologic symptoms in their experience with intrathecal preservative-free normal saline challenge in patients with SIH. However, their injection rate was reported at 1 mL/min in contrast to our fast injection rate of 1 mL/s, and even higher average volumes of saline were injected in their study (75.8 mL).…”

“…Additionally, varying amounts of sterile preservative-free normal saline (Baxter) were injected before main contrast runs in an attempt to create positive intrathecal pressure and facilitate a CSF leak, which can be intermittent, thereby improving detection of the leak. 21,22 The volume of saline injected was variable and ultimately based on operator preference. Both 20-and 22-ga Quincke spinal needles (Becton Dickinson) were used, and this was also based on operator preference and consideration of factors such as patient body habitus.…”

Epidural blood patch for spontaneous intracranial hypotension (SIH): a report of two cases

“…[6][7][8][9] Common presentation may be with associated dizziness, behavioural disturbance, vomiting and altered sensorium. 10,11 A high index of suspicion of SIH is required in all patients with orthostatic symptoms, particularly in young and middle-aged patients with new-onset, persistent daily headaches. Typically, the symptoms occur immediately or within seconds to minutes of assuming an upright position and resolve within minutes after lying supine.…”

Prof Cerebrospinal CNS-Leaks: State of the Art in Imaging Diagnosis with Special Focus on Intrathecal MRI Paramagnetic Contrast Agents Procedures

“…This difference may reflect a combination of improved tissue contrast resolution for MRI compared with CT as well as the substantial delay in imaging for CE-MRM 126 . When pressureaugmented decubitus dynamic CE-MRM is performed the pressure augmentation is anticipated to increase the conspicuity of extrathecal contrast material originating through slow or subtle leaks 181 . Using these combinations of techniques, several leaks that were occult on DCTM or NCHRT2W-MRM imaging could be detected.…”