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Published on: July 11, 2019
Sacral CSF-venous fistula: a rare entity. Illustrative case
Alexander Mastrolonardo1, Annika R Mascarenhas1, Keith MacDougall1
1Department of Clinical Neurological Sciences, Western University, London, Ontario.
Insights
A rare sacral cerebrospinal fluid-venous fistula (CVF) causing spontaneous intracranial hypotension (SIH) was successfully treated. Advanced imaging confirmed the fistula, leading to effective transvenous embolization.
Area of Science:
- Neurosurgery
- Interventional Radiology
- Neuroradiology
Background:
- Cerebrospinal fluid-venous fistulas (CVFs) are increasingly recognized causes of cerebrospinal fluid (CSF) leakage.
- Spontaneous intracranial hypotension (SIH) can result from CSF leakage.
- CVFs are typically found in the thoracolumbar spine, with sacral CVFs being rare.
Purpose of the Study:
- To report a case of a sacral CVF causing SIH.
- To highlight the diagnostic challenges and imaging techniques for sacral CVFs.
- To demonstrate the successful treatment of a sacral CVF via transvenous embolization.
Main Methods:
- A patient with SIH underwent diagnostic imaging, including CT and MRI.
- Lateral decubitus CT myelography (CTM) and digital subtraction myelography (DSM) were utilized to identify a sacral CVF.
- Transvenous embolization using Onyx-18 was performed for fistula obliteration.
Main Results:
- SIH symptoms were attributed to a sacral CVF at the L5-S1 level.
- Advanced imaging techniques (CTM and DSM) successfully localized the rare sacral fistula.
- Transvenous embolization resulted in complete obliteration of the CVF.
Conclusions:
- This case represents the third reported instance of a sacral CVF.
- Advanced imaging is crucial for diagnosing CVFs when routine studies are inconclusive.
- Technical considerations for CTM and DSM of the sacral region are important for accurate diagnosis.
Background:
CSF-venous fistula (CVF) is an increasingly recognized cause of CSF leakage resulting in spontaneous intracranial hypotension (SIH). CVFs are most commonly identified in the thoracolumbar spine and are rarely reported in the sacral region.
Observations:
A man in his 60s presented with symptoms consistent with SIH. CT of the brain demonstrated bilateral subdural hematomas and a decreased pontomesencephalic angle. Spinal MRI showed degenerative changes without evidence of a CSF leak. Lateral decubitus CT myelography (CTM) with delayed imaging identified a sacral CVF at the L5-S1 level, which was confirmed with an adjusted technique within digital subtraction myelography (DSM). The fistula was determined to be the etiology of the patient's symptoms. Transvenous embolization via femoral venous access using Onyx-18 resulted in successful obliteration of the fistula.
Lessons:
This case represents only the third reported sacral CVF. It highlights the importance of advanced diagnostic imaging when routine studies are negative but clinical suspicion for SIH remains high. Key technical considerations for CTM and DSM of the lumbosacral junction and sacrum are discussed. https://thejns.org/doi/10.3171/CASE2632.
