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MR Cisternography Localizes CSF Leaks in Spontaneous Intracranial Hypotension

February 15, 2008
Written by: , Filed in: Neuroradiology
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Background
Spontaneous intracranial hypotension (SIH) occurs secondary to cerebrospinal fluid CSF leaks in the spine, which are treated with epidural blood patch or surgery. To date, the best study for detecting these leaks is CT myelography/cisternography, which has a sensitivity of 67% for detecting leaks and carries a high dose of radiation.

The objective of a recent retrospective study was to report the results of using intrathecal gadolinium administration for detecting CSF leaks in the setting of SIH.

The results have shown that MR cisternography is a safe and sensitive method of detecting spinal CSF leaks in the setting of spontaneous intracranial hypotension. Its sensitivity for detecting leaks is 89%.

Participants
19 patients with SIH who underwent MR cisternography.

Methodology
After failed conservative treatment of SIH, MR cisternography was performed, mixing 4 mL of saline with 0.5 mL of gadopentetate dimeglumine (Magnevist) and injecting this into the subarachnoid space. Patients stayed in elbow-knee position for 15 minutes and, 1 hour later, MRI was performed in the supine position. Sagittal, axial, and coronal T1 fat-suppressed images were obtained, and the patients were observed for 24 hours. Neurologic follow-up was performed for 12 months.

Neuroradiology Review

The Johns Hopkins University School of Medicine
Course Directors: David Yousem, MD, MBA and Doris Lin, MD, PhD Maintaining certification requires not only medical knowledge to deliver quality care but also other essential elements that must be developed and maintained throughout every radiologist’s career. Therefore, this program serves as a comprehensive review of neuro-radiology and prepares the participants to tackle imaging of the brain, spine, head and neck, as well as the vascular anatomy of the central nervous system. Click here to read more or order: Neuroradiology Review

Results of the Study
No neurologic or other clinical changes were detected in any patients in the immediate 24 hours after the procedure or in the subsequent 24 months, except for increased orthostatic headache in five patients (explained by lumbar puncture). The images demonstrated total enhancement of the subarachnoid space. Leaks were detected in 17 of 19 patients (89%).

In three of these patients, the leak was too large to accurately determine the site of leakage. In 10 patients, there was a single leak site, whereas in four, there were multiple leaks. One of these patients had more than two dural tears.

In 17 patients with leaks, the leaks were solely paravertebral in four and were both paravertebral and epidural in 13. Eleven patients demonstrated meningeal diverticula.

Conclusions
MR cisternography is a safe and effective method for evaluating CSF leaks in SIH (sensitivity, 89%), which is better than CT (sensitivity, 67%). It is also preferred to CT due to the absence of the high degree of radiation used in CT studies, particularly in children and young adults. Long-term studies will be necessary to assess for potential complications, such as arachnoiditis.

Reviewer’s Comments
Clearly, the time has come for MR myelography/cisternography in this setting, particularly as we are becoming more concerned with the potential adverse effects of radiation. Unfortunately, the authors did not address the technical parameters they used, including slice thickness needed to attain such excellent results and the length of the study.

Author: Yaron Lebovitz, MD

Reference:
Albayram S, Kilic F, et al. -Enhanced MR Cisternography to Evaluate Dural Leaks in Intracranial Hypotension Syndrome.
AJNR Am J Neuroradiol; 2008; 29 (January): 116-121

Neuroradiology Review

The Johns Hopkins University School of Medicine
Course Directors: David Yousem, MD, MBA and Doris Lin, MD, PhD Maintaining certification requires not only medical knowledge to deliver quality care but also other essential elements that must be developed and maintained throughout every radiologist’s career. Therefore, this program serves as a comprehensive review of neuro-radiology and prepares the participants to tackle imaging of the brain, spine, head and neck, as well as the vascular anatomy of the central nervous system. Click here to read more or order: Neuroradiology Review
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