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Under Pressure: Advancing the Diagnosis of Pediatric CSF Leaks with Digital Subtraction Myelography
Catherine M Garcia1, Daniel Chang2, Marcel M Maya3
1From the Department of Neurosurgery (C.M.G., D.C., W.I.S.), Cedars-Sinai Medical Center, Los Angeles, California Catherine.garcia@cshs.org.
Insights
Digital subtraction myelography (DSM) is a safe and effective tool for diagnosing pediatric cerebrospinal fluid (CSF) leaks, enabling precise localization for targeted treatment. This technique improves outcomes for children experiencing intracranial hypotension.
Area of Science:
- Neurology
- Radiology
- Pediatric Medicine
Background:
- Intracranial hypotension, caused by cerebrospinal fluid (CSF) leaks, leads to debilitating orthostatic headaches and neurological symptoms.
- Pediatric CSF leaks present unique management challenges due to limited specific data.
- Digital subtraction myelography (DSM) shows promise as a sensitive method for visualizing these leaks.
Purpose of the Study:
- To review the application of DSM in diagnosing and localizing CSF leaks in pediatric patients.
- To evaluate the safety and efficacy of DSM in a pediatric population at a specialized center.
Main Methods:
- Analysis of prospective registries of pediatric patients (≤19 years) evaluated for CSF leaks between 2001 and 2025.
- Standardized DSM protocols were employed, with positional adjustments based on suspected leak sites.
- Data collected included demographics, clinical presentation, imaging results, and patient outcomes.
Main Results:
- Seventy-three DSMs were performed on 41 pediatric patients (27 female, 14 male; mean age 15.69 years).
- No complications were reported; average fluoroscopy time was 1.8 minutes, with a mean radiation dose of 324.8 mGy.
- DSM identified leaks in 57.1% of patients with suspected spontaneous intracranial hypotension and 46.2% with traumatic or iatrogenic leaks, with high concordance with surgical findings.
Conclusions:
- DSM is a safe and effective diagnostic modality for pediatric CSF leaks, crucial for precise localization and targeted therapy.
- Integrating DSM into diagnostic workflows can enhance outcomes for children with intracranial hypotension.
- Further multicenter research is recommended to validate these findings and refine DSM protocols.
Background And Purpose:
Intracranial hypotension-arising from CSF leaks that are iatrogenic, traumatic, or spontaneous-is a potentially debilitating condition resulting in orthostatic headaches and other neurologic symptoms. While pediatric CSF leaks are challenging to manage due to limited data, digital subtraction myelography (DSM) has shown promise as a highly sensitive diagnostic tool for visualizing these leaks. This study reviews the use of DSM in pediatric patients for diagnosing and localizing CSF leaks at a quaternary center for intracranial hypotension.
Materials And Methods:
Using prospective registries, we analyzed pediatric patients (19 years of age or younger) evaluated for CSF leaks at our institution between 2001 and 2025. Patients underwent DSM under standardized protocols, including adjustments for positioning based on suspected leak locations. Data on demographics, clinical presentation, imaging findings, and outcomes were also analyzed.
Results:
Forty-one patients (27 females, 14 males; mean age, 15.69 [SD, 3.12] years) underwent 73 DSMs. The average fluoroscopy time was 1.8 (SD 1.4) minutes, and the mean kinetic energy released per unit mass (air kerma) radiation dose was 324.8 (SD, 373.8) mGy. No complications were reported. Among 28 patients with suspected spontaneous intracranial hypotension (SIH), 54 DSMs were performed; orthostatic headache was the presenting symptom in 96.4%. Eighteen leaks were identified in 16 patients (57.1%), most commonly type 1b (33.3%) and type 3 (27.8%) leaks. Of 15 patients undergoing surgery, intraoperative findings confirmed DSM results in 14 cases. Thirteen patients with traumatic or iatrogenic leaks underwent 19 DSMs; orthostatic headache was present in 92.3%. Eight leaks were identified in 6 patients (46.2%), predominantly ventral, and all underwent directed interventions.
Conclusions:
DSM is a safe and effective diagnostic technique for pediatric CSF leaks, enabling precise localization critical for targeted treatment. Incorporating DSM into the diagnostic workflow may improve outcomes for children with intracranial hypotension, but further multicenter studies are needed to validate findings and optimize protocols.
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