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MDCT Findings to Detect and Localize Cerebrospinal Fluid (CSF) Leakage in Patients with Spontaneous Intracranial Hypotension (SIH) 2013

Category General Spine Kyung Ryeol Lee
Guen Young Lee
Seung Woo Choi
Joon Woo Lee
Heung Sik Kang
Purpose The detection and localization of cerebrospinal fluid (CSF) leakage in patients with spontaneous intracranial hypotension (SIH) is important. The aim of this study was to evaluate the usefulness of multidetector CT (MDCT)-myelography in patients with SIH. Materials & Methods A radiologist retrospectively searched the electronic database to find the patients who had undergone MDCT-myelography for SIH between October 2010 and November 2011. In the MDCT-myelographic treatment, the patient’s whole spine was scanned by 64 or 256 channel multidetector CT scanners (BRILIANCE 64 or ICT 256, PHILIPS, Cleveland, USA) after being injected with 20 ml of contrast agent via L3/4 interlaminar space under fluoroscopic guidance. Based on myelography and MDCT-myelography, two radiologists in consensus determined the presence, pattern (“pseudodiverticular sign” or “gray-rim sign”) and level of contrast leakage outside the dural sac. Clinical outcome after targeted epidural blood patch was evaluated by retrospective chart review. Results Seven patients (M:F = 4:3; mean age, 40.6; age range, 17–56) were finally included in this study. CSF leakage was detected in six of seven patients. CSF leakage pattern was described as a “pseudodiverticular sign” in two and “gray-rim sign” in four patients. Leakage level could be determined in five patients based on MDCT-myelography. Targeted epidural blood patches were performed for the suspected CSF leakage levels in the five patients according to radiologic report and all five patients showed dramatic symptom improvement after procedures. Conclusion MDCT-myelography was useful to detect CSF leakage and to guess the leakage level in patients with SIH. References 1. Park ES, Kim E. Spontaneous Intracranial Hypotension: Clinical Presentation, Imaging Features and Treatment. J Korean Neurosurg Soc 2009;45:1–4 2. Wouter I, David W, Bahram M, et al. Diagnostic Criteria for Headache Due to Spontaneous Intracranial Hypotension: A Perspective. Headache 2011 Jun 9. Doi: 10. 1111 3. Schievink WI, Maya MM, Loucy C, et al. Diagnostic Criteria for Spontaneous Spinal CSF Leaks and Intracranial Hypotension. Am J Neuroradiol 2008;29:853–56. 4. Cho KI, Moon HS, et al. Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch. Neurology 2011;76:1139–44. 5. Waguri N, Tomita M, et al. Epidural Blood Patch for Treatment of Spontaneous Intracranial Hypotension. Acta Anaesthesiol Scand 2002;46:747–750. 6. Kranz PG, Gray L, Taylor JN. CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension. Am J Neuroradiol 2011;32:832–38. 7. Patrick H, Mokri B. Dynamic CT Myelography: A Technique for Localizing High-Flow Spinal Cerebrospinal Fluid Leaks. Am J Neuroradiol 2003;24:1711–1714. 8. Fujimaki H, Saito N, Tosaka M, et al. Cerebrospinal Fluid Leak Demonstrated by Three-dimensional Computed Tomographic Myelography in Patients with Spontaneous Intracranial Hypotension. Surg Neurol 2002;58:280–5. 9. Selcuk H, Albayram S, Ozer H, et al. Intrathecal Gadolinium-Enhanced MR Cisternography in the Evaluation of CSF leakage. Am J Neuroradiol 2010;31:71–75. 10. Albayram S, Kilic F, Ozer H, et al. Gadolinium-enhanced MR Cisternography to Evaluate Dural Leaks in Intracranial Hypotension Syndrome. Am J Neuroradiol 2008;29:116–21. 11. Watanabe A, Horikoshi T, Uchida M, et al. Diagnostic Value of Spinal MR imaging in Spontaneous Intracranial Hypotension Syndrome. Am J Neuroradiol 2009;30:147–51. 12.  Wang YF, Lirng JF, Fuh JL, et al. Heavily T2-weighted MR myelography vs CT myelography in spontaneous intracranial hypotension. Neurology 2009; 73(22):1892–8.