Journal Article: Dynamic CT Myelography


A Technique for Localizing High-Flow Spinal Cerebrospinal Fluid Leaks

We’ve added an interesting journal article on the use of dynamic CT Myelography in locating the site of a high-flow cerebrospinal fluid (CSF) leak. You can download the article by clicking here.


In some patients with spontaneous spinal CSF leaks, leaks are numerous or tears are so large that extrathecal myelographic contrast material is seen at multiple levels during CT, making identification of their source impossible. This study introduces a dynamic CT myelographic technique that provides high temporal and spatial resolution. In this technical note, we describe the utility of this technique in four patients with challenging high-flow spinal CSF leaks.



Headache secondary to intracranial hypotension


Author Information

Schievink WI1, Deline CR.

1Department of Neurosurgery, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, Sixth Floor, A-6600, Los Angeles, CA, 90048, USA,


Intracranial hypotension is known to occur as a result of spinal cerebrospinal fluid (CSF) leaking, which may be iatrogenic, traumatic, or spontaneous. Headache is usually, but not always, orthostatic. Spontaneous cases are recognized more readily than in previous decades as a result of a greater awareness of clinical presentations and typical cranial magnetic resonance imaging findings. An underlying disorder of connective tissue that predisposes to weakness of the dura is implicated in spontaneous spinal CSF leaks. CT, MR, and digital subtraction myelography are the imaging modalities of choice to identify spinal CSF leakage. Spinal imaging protocols continue to evolve with improved diagnostic sensitivity. Epidural blood patching is the most common initial intervention for those seeking medical attention, and may be repeated several times. Surgery is reserved for cases that fail to respond or relapse after simpler measures. While the prognosis is generally good with intervention, serious complications do occur. More research is needed to better understand the genetics and pathophysiology of dural weakness as well as physiologic compensatory mechanisms, to continue to refine imaging modalities and treatment approaches, and to evaluate short- and long-term clinical outcomes.

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New CSF Leak Journal Articles


We’ve added three additional journal articles to our downloads section.

Two articles about the use of gadolinium in CSF Leak detection:

One review paper by Dr Wouter Schievink of Cedars-Sinai Hospital, California:

Spinal Meningeal Diverticula in Spontaneous Intracranial Hypotension


Authors: P.G. Kranza, S.S. Stinnettb, K.T. Huanga and L. Graya


BACKGROUND AND PURPOSE: Spinal meningeal diverticula have been implicated in the pathogenesis of spontaneous intracranial hypotension and have been proposed as both diagnostic features of and therapeutic targets for the condition. We compared the prevalence and myelographic appearance of spinal diverticula in patients with SIH and healthy controls.

MATERIALS AND METHODS: Patients satisfying the ICHD-2 criteria for SIH were retrospectively identified. CT myelograms of 19 patients with SIH were compared with CT myelograms of 18 control patients. Images were reviewed by 2 blinded neuroradiologists. The prevalence, morphology (round versus multilobulated), size, and location (cervical, upper thoracic, lower thoracic, or lumbar) of spinal meningeal diverticula were analyzed.

RESULTS: There was no difference in the proportion of patients with diverticula in the SIH group compared with the control group (68% versus 44%, P = .14) or in the mean number of diverticula per patient (6.3 versus 2.2, P = .099). No difference was seen in the morphology (P = .95) or size (P = .71) of diverticula between groups. There was a difference between groups that just reached statistical significance (P = .050) in the location of the diverticula along the spinal axis, but substantial overlap was seen between groups for all spinal locations.

CONCLUSIONS: Despite the well-established association between spinal meningeal diverticula and SIH, we found no difference in the prevalence  or myelographic appearance of diverticula in patients with SIH compared with controls. Further investigation into the role of diverticula in the diagnosis and treatment of SIH is necessary.

© 2013 by American Journal of Neuroradiology

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Diagnostic Criteria for Spontaneous Spinal CSF Leaks and Intracranial Hypotension


Authors: W.I. Schievinka, M.M. Mayab, C. Louyc,  F.G. Moserb and J. Tourjeb


BACKGROUND AND PURPOSE: Comprehensive diagnostic criteria encompassing the varied clinical and radiographic manifestations of spontaneous intracranial hypotension are not available. Therefore, we propose a new set of diagnostic criteria.

MATERIALS AND METHODS: The diagnostic criteria are based on results of brain and spine imaging, clinical manifestations, results of lumbar puncture, and response to epidural blood patching. The diagnostic criteria include criterion A, the demonstration of extrathecal CSF on spinal imaging. If criterion A is not met, criterion B, which is cranial MR imaging findings of spontaneous intracranial hypotension, follows, with at least one of the following: 1) low opening pressure, 2) spinal meningeal diverticulum, or 3) improvement of symptoms after epidural blood patch. If criteria A and B are not met, there is criterion C, the presence of all of the following or at least 2 of the following if typical orthostatic headaches are present: 1) low opening pressure, 2) spinal meningeal diverticulum, and 3) improvement of symptoms after epidural blood patch. These criteria were applied to a group of 107 consecutive patients evaluated for spontaneous spinal CSF leaks and intracranial hypotension.

RESULTS: The diagnosis was confirmed in 94 patients, with use of criterion A in 78 patients, criterion B in 11 patients, and criterion C in 5 patients.

CONCLUSIONS: A new diagnostic scheme is presented reflecting the wide spectrum of clinical and radiographic manifestations of spontaneous spinal CSF leaks and intracranial hypotension.

Copyright © American Society of Neuroradiology

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Role of MR Myelography with Intrathecal Gadolinium in Localization of Spinal CSF Leaks



mri-gadolinium-contrastA, Pre- and post-intrathecal gadolinium fat-suppressed T1 images demonstrate typical artifacts, which may simulate a leak at C1-C2 seen in 6 of 41 of our patients. Note the inhomogeneous fat saturation on this precontrast sagittal T1 image at C1-2 (arrow). B, Recognizing this artifact on precontrast imaging is important because with the addition of intrathecal gadolinium, this inhomogeneous fat saturation can potentially mimic a leak (arrow).

Full article and images available here:

Detection of CSF Leak in Spinal CSF Leak Syndrome Using MR Myelography




Schematic drawing of 4-point-scale grading system of CSF leak on MRM (A) and RIC (B). A, Our grading scale on MRM is depicted as follows: grade zero, no leak (normal findings on MR myelogram); grade 1, possible leak (expansion of the CSF space column around the nerve root sleeve); grade 2, probable leak (streaky hyperintensity lateral to the nerve root sleeves but with length less than the transverse diameter of the thecal sac); and grade 3, definite leak (lateral extension greater than the transverse diameter of the thecal sac). However, actual grading of the case is determined on the basis of the highest grade in each level of the spine. B, Grade of CSF leak on RIC is depicted as follows: grade zero, no paraspinal activity; grade 1, possible leak (faint paraspinal activity with length under the transverse diameter of spinal canal activity); grade 2, probable leak (hot paraspinal activity with the length under the transverse diameter of spinal canal activity); and grade 3, definite leak (hot paraspinal activity with the length over the transverse diameter of spinal canal activity)‏

Full article and PowerPoint presentation available here:

The Value of Changing Position in the Detection of CSF Leakage


ABSTRACT: Radionuclide Cisternography (RNC) is of potential value in pointing out the sites of cerebrospinal fluid (CSF) leakage in patients with spontaneous intracranial hypotension (SIH). In the current report, we present two patients who underwent RNC for suspected CSF leakage. Both patients underwent magnetic resonance imaging (MRI) and RNC for evaluation. We describe a simple method to increase the detection ability of RNC for CSF leakage in patients with SIH.

Headache Journal: Spontaneous Cerebrospinal Fluid (CSF) Leaks


Spontaneous cerebrospinal fluid (CSF) leaks typically present with orthostatic headaches. Less commonly, spontaneous CSF leaks can present with other headache types. Nausea, vomiting, hearing disturbances, diplopia, back pain, and dizziness are not uncommon associated symptoms. Although the exact cause of CSF leaks often remains uncertain, some patients may be predisposed due to disorders of connective tissue or spinal meningeal anomalies.

When a spontaneous CSF leak is suspected, head MRI with contrast is ordinarily the first study to obtain. Common abnormalities seen include diffuse dural enhancement, subdural fluid collections, engorged cerebral venous sinuses, and cerebral descent. Important to know is the fact that despite typical clinical features, head MRI may occasionally be unremarkable. In such situations, ancillary studies may help answer whether a CSF leak is present. Radioisotope cisternography and spine MRI are helpful tools in such occurrences. Presently, CT-myelography remains the most reliable test to find the exact spinal CSF leak site. Often, however, the exact CSF leak site is not found.

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