Imaging of SIH: Past, Current and Future ... - Spinal CSF Leak

Imaging of SIH: Past, Current and Future Modalities

Marcel Maya, MD

Cedars Sinai

CSF LEAK

Imaging

• Radionuclide Cisternography

• MRI Brain

• MRI Spine

• MR Myelogram

• Intrathecal Gado MR Spine

• Conventional CT Myelogram

• Dynamic CT guided Myelogram

• Digital Subtraction Myelogram

Radionuclide Cisternography

Paucity of activity over the convexities

Parathecal activity

Not good for localizing site of leak

Helpful when all else is unconvincing

Imaging

• Radionuclide Cisternography

• MRI Brain

• MRI Spine

• MR Myelogram

• Intrathecal Gado MR Spine

• Conventional CT Myelogram

• Dynamic CT guided Myelogram

• Digital Subtraction Myelogram

Monro-Kellie Hypothesis

Hypotension or Hypovolemia?

CSF hypovolemia(CSF volume depletion)

DecreasedCSF pressure

ClinicalManifestations

MRI abnormalities

Headache can be absent MR maybe

normal

Pressure can be normal

Intracranial Hypotension/Hypovolemia

• Pachymeningeal enhancement

• Brain “sagging” or “sinking”

• cerebellar tonsils low

• brainstem distortion

• Pontine enlargement

• crowding of the posterior fossa

• flattening of the optic chiasm

• Subdural hygromas/hematomas

• Engorged venous sinuses

• Pituitary hyperemia

Cranial MRI

S Subdural hygroma/hematomaE Enhancement of pachymeningesE Enlargement of veinsP Pituitary hyperemiaS Sagging of brain

Cranial MRI

PRE and POST Treatment

Frontotemporal Dementia

SDH due to CSF leak

Direct proof of spinal CSF leakage in 25.9% of patients suggests that spinal CSF leaks may be a frequent cause of nongeriatric CSDH

Siderosis

Spinal Leak Detection and Localization

Classification of CSF Leaks

Incidence

Type 1 Dural Tear 26.6%

Type 2 Meningeal Diverticulum 42.3%

Type 3 CSF Venous Fistula 2.5%

Type 4 Indeterminate 28%

Classification of CSF Leaksrecent data since April 2018

Incidence

Type 1 Dural Tear 40%

Type 2 Meningeal Diverticulum 17%

Type 3 CSF Venous Fistula 23%

Type 1 (Dural tear)

False localizing C1-2

Ventral Leak DSM

Ventral Leak Dynamic CT guided Myelogram

Type 2 (Meningeal diverticulum)

Type2 (Meningeal diverticulum)

Type 3 (CSF Venous Fistula)

CSF Venous Fistula

DSM in lateral decubitus position

23 new patients April-September 2018

16 patients positive for fistula

DSM LATERAL DECUBITUS

Spinal Leak Detection and Localization

Modality Initial High Flow Low Flow Radiation

CTM +++ + ++ 10-30 mSv

Dynamic CTM - ++ + 20-200

DSM ? +++ + 2-35

MR/MYELO +++ - + 0

MR IT Gado - - ++ 0

Radionuclide - ++ 2-6

Kranz et al AJR

Thank You

Percutaneous Treatment: Cedars-Sinai Approach

Charles Luoy and Marcel Maya

Cedars Sinai

Fig 15: Clinical management algorithm

Classification of CSF Leaks

Incidence

Type 1 Dural Tear 26.6%

Type 2 Meningeal Diverticulum 42.3%

Type 3 CSF Venous Fistula 2.5%

Classification of CSF Leaksrecent data since April 2018

Incidence

Type 1 Dural Tear 40%

Type 2 Meningeal Diverticulum 17%

Type 3 CSF Venous Fistula 23%

Interventional Options

• Blood Patch

• Single level

• Multilevel

• Targeted

• Fibrin Glue

Year Blood Patch Fibrin Glue

2013 138 46

2014 160 34

2015 169 40

2016 209 51

Fibrin Glue

Fibrin Glue CSF fistula

Pre Treatment Post Treatment

Sacral cysts

Meningeal diverticulum

Results

Epidural blood patch

30-70% initial response

Relapse not uncommon

Maintenance patching may be necessary

Percutaneous glue

40% cure rate

Depends on accurate localization of leak

Imaging of SIH: Past, Current and Future ... - Spinal CSF Leak

Documents

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SIH 2013 03MAR