The Role of MR Myelography with Intrathecal Gadolinium in Localization of Spinal CSF Leaks in Patients with Spontaneous Intracranial Hypotension

Akbar, J. J.; Luetmer, Patrick H.; Schwartz, Kara M.; Hunt, Christopher H.; Diehn, Felix E.; Eckel, L. J.

doi:10.3174/ajnr.a2815

Cited by 103 publications

(69 citation statements)

References 21 publications

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“…However, our finding of a higher rate of leak detection with MRM compared with CTM is in accordance with recently published studies. 11 We found a leak at MRM in 9 of 24 patients (38%) with clinical symptoms and imaging findings of SIH, similar to findings in a recent study by Akbar et al, 10 which detected a leak on MRM in 5 of 24 patients (21%) with negative CTM findings. Despite our cohort of diagnostically challenging patients, we recognize the benefit of MRM and advocate MRM examinations early in the diagnostic work-up.…”

Section: Discussionsupporting

confidence: 76%

“…8 Recent literature has questioned whether CTM is the most sensitive technique for the detection and localization of CSF leaks. 9,10 More recent techniques have been described, including dynamic CTM, digital subtraction myelography, heavily T2-weighted spinal MR imaging, and intrathecal gadolinium MR myelography (MRM). Both dynamic CT and digital subtraction myelography have been advocated in cases with significant spinal extra-arachnoid fluid collections on preprocedural spinal MR imaging.…”

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confidence: 99%

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MR Myelography for Identification of Spinal CSF Leak in Spontaneous Intracranial Hypotension

Chazen

Talbott

Lantos

et al. 2014

AJNR Am J Neuroradiol

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Section: Discussionsupporting

confidence: 76%

mentioning

confidence: 99%

MR Myelography for Identification of Spinal CSF Leak in Spontaneous Intracranial Hypotension

Chazen

Talbott

Lantos

et al. 2014

AJNR Am J Neuroradiol

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“…Intrathecal gadolinium MR myelography continues to be a useful technique in the highly selected group of patients with debilitating symptoms of SIH and a negative conventional CTM. 10 Although we have historically performed delayed imaging at 3-4 hours after intrathecal injection of contrast when initial imaging fails to show a leak, this proposed algorithm also removes delayed CTM images, as delayed imaging adds radiation dose and does not add significant value, based on the results of our study.…”

Section: Discussionmentioning

confidence: 76%

When Should I Do Dynamic CT Myelography? Predicting Fast Spinal CSF Leaks in Patients with Spontaneous Intracranial Hypotension

Luetmer¹,

Schwartz²,

Eckel³

et al. 2011

AJNR Am J Neuroradiol

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103

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“…2,8,19 However, even CEMRM does not identify a significant proportion (that is, 63%-79%) of CSF leakage sites. 2,8 The possible causes for this shortcoming include transient CSF leakage, which may therefore not occur during the scanning interval during imaging, very small leaks that are below the resolution threshold of current imaging techniques, and very-low-pressure CSF leaks resulting from markedly low intrathecal pressure.…”

Section: Resultsmentioning

confidence: 99%

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

Griauzde¹,

Gemmete²,

Pandey³

et al. 2015

JNS

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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.

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The Role of MR Myelography with Intrathecal Gadolinium in Localization of Spinal CSF Leaks in Patients with Spontaneous Intracranial Hypotension

Cited by 103 publications

References 21 publications

MR Myelography for Identification of Spinal CSF Leak in Spontaneous Intracranial Hypotension

MR Myelography for Identification of Spinal CSF Leak in Spontaneous Intracranial Hypotension

When Should I Do Dynamic CT Myelography? Predicting Fast Spinal CSF Leaks in Patients with Spontaneous Intracranial Hypotension

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

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