Intrathecal Gadolinium-Enhanced MR Cisternography Improves the Detection of Skull Base CSF Leaks

To compare the efficacy of contrast enhanced magnetic resonance cisternography (CE-MRC), computed tomography cisternography (CTC), and single-photon emission computed tomography (SPECT-CT) radionuclide cisternography (RNC) in detection of skull base cerebrospinal fluid (CSF) leaks.

Retrospective cohort study.

Tertiary referral center.

Adult patients with suspected anterior skull base (ASB) or lateral skull base (LSB) CSF leak who underwent CE-MRC, CTC, and/or SPECT-CT RNC to assess for CSF leak from 2018 to 2024.

Evidence of CSF leak on single or multiple cisternogram types.

Fifty patients (74% female) had a mean (standard deviation) age of 50 (17) years and a median BMI of 34 (IQR, 28-42) kg/m 2 . Nineteen patients had a surgically or laboratory-confirmed CSF leak. Of these, 78% were spontaneous CSF leaks. There were no false-positive tests for any mode of cisternograms. CT cisternograms had a sensitivity of 53% (ASB: 86%, LSB: 33%) compared with a sensitivity of 90% (ASB: 100%, LSB: 86%) for CE-MR cisternograms and 67% (ASB: 100%, LSB: 33%) for SPECT-CT RN cisternograms.

CE-MRC appears to be more sensitive than CTC and SPECT-CT RNC in detecting skull base CSF leaks, particularly in the lateral skull base. CE-MRC should be used when appropriate in combination with high-resolution CT to assess for CSF leaks when there is a high index of suspicion with inconclusive beta-2 transferrin testing.

4.