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Locating Spinal Leaks in Spontaneous Intracranial Hypotension: How Many Dynamic Myelographies Does It Take?
Saujanya Rajbhandari1, Thomas Petutschnigg2, Levin Häni2
1From the Department of Diagnostic and Interventional Neuroradiology (S.R., P.B., L.G., J. Gralla, S.P.-P., J.K. E.I.P., T.D.), Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
Dynamic myelography accurately pinpoints cerebrospinal fluid (CSF) leaks in spontaneous intracranial hypotension (SIH) patients. While the first exam localizes leaks in about half of cases, repeat dynamic myelography refines localization, especially for challenging dorsal leaks.
Area of Science:
- Radiology
- Neurosurgery
- Neurology
Background:
- Spontaneous intracranial hypotension (SIH) necessitates precise localization of cerebrospinal fluid (CSF) leaks for effective targeted therapy.
- Spinal longitudinal extradural CSF collections (SLECs) are a common finding in SIH patients requiring diagnostic evaluation.
Purpose of the Study:
- To assess the accuracy of dynamic myelography techniques in localizing spinal CSF leaks in SIH patients.
- To determine the number of examinations required for leak localization, stratified by leak type and spinal level.
Main Methods:
- A retrospective review of consecutive SIH patients with SLEC investigated between January 2013 and February 2025.
- Dynamic myelography, including conventional dynamic myelography (CDM) and/or dynamic computed tomography myelography (DCTM), was used to identify the spinal CSF leak level.
Main Results:
- 198 SLEC-positive SIH patients were included, with 147 (74%) having ventral, 49 (25%) lateral, and 2 (1%) dorsal leaks.
- The median number of myelography exams to localize a leak was 2, with ventral leaks requiring fewer (median 1) than lateral (median 2) and dorsal (median 6) leaks.
- 81% of patients were referred for microsurgical closure, with 96% of dural leaks identified correctly at the indicated vertebral level intraoperatively.
Conclusions:
- Dynamic myelography is accurate and reliable for localizing spinal CSF leaks in SIH patients with SLECs.
- Approximately 49% of leaks are localized with the first dynamic myelography exam.
- Repeat dynamic myelography allows for technique and patient positioning adjustments, crucial for rare but challenging dorsal leaks.
