An Uncommon Case of Multiple, Recurrent Cerebrospinal Fluid Venous Fistulas

We present a clinical case to discuss the use of computed tomography (CT) spine myelograms alongside a complete history to diagnose multiple cerebrospinal fluid (CSF) venous fistulas (CVFs). The goal of this study is to familiarize clinicians with this challenging diagnosis and the utility of these studies in localizing leaks. A 63-year-old male patient with a history of cervical spinal stenosis, intermittent double vision, and sinus pressure managed with intermittent steroids presented to the clinic. He provided a detailed timeline of his previous symptoms and previous workups leading to the suspicion of intracranial hypotension due to CSF leak vs. CVF. Our workup, including magnetic resonance imaging (MRI) of the cervical spine and lumbar puncture (LP), was conducted. A CT thoracic spine myelogram was completed to localize the fistula site which was followed by the embolization of the fistula. The patient revealed complete resolution of his symptoms confirmed by imaging done one week postoperatively. This was a difficult case complicated by chronic misdiagnosis and confounding factors. CVFs were first described less than a decade ago; however, they are an extremely important cause of spontaneous intracranial hypotension. CVFs can be challenging to detect on conventional anatomical imaging like MRI. Thus, CT myelogram studies and a thorough history are crucial for accurate diagnosis. It is essential that clinicians, including ophthalmologists, learn to recognize CVFs as a potential cause of intracranial hypotension and become familiar with this diagnosis and its workup in the hopes that, unlike this case, the diagnosis and resolution of patients' life-altering symptoms are not delayed.