Treatment of Spinal CSF Leaks and Fistulas

The options for treatment of spontaneous spinal CSF leaks and CSF-venous fistulas have expanded in recent years, and this article reviews the current treatments available, factors that affect treatment outcomes, and an algorithmic approach to treatment.

Until recently, treatments for spontaneous intracranial hypotension consisted of supportive care, epidural blood patching, and when the site of CSF leakage was known, surgical repair. CSF-venous fistulas are now known to be common causes of CSF hypotension and are rarely cured by epidural blood patching. Better visualization of CSF-venous fistulas and the novel treatment of CSF-venous fistulas with transvenous embolization have expanded the arsenal of treatment options for spontaneous intracranial hypotension.

Clinical outcomes improve with timely treatment of spinal CSF leaks and CSF-venous fistulas. Radiographic features direct treatment, which includes epidural blood patching, transvenous embolization, and surgical correction. CSF-venous fistulas respond poorly to epidural blood patching but can respond favorably to surgical obliteration or transvenous embolization.