Advanced CT Myelography for Spontaneous Cerebrospinal Fluid Leaks

Spontaneous intracranial hypotension is a frequently debilitating condition that is most commonly caused by loss of cerebrospinal fluid (CSF) from the spine. The most frequently occurring types of spontaneous spinal CSF leaks that cause spontaneous intracranial hypotension are ventral dural tears, lateral dural tears, and CSF venous fistulas, but other leak types are recognized including sacral dural tears or fistulas into vascular malformations. Localization and characterization of spinal CSF leaks with CT myelography facilitates subsequent targeted treatment. A tailored approach based on the suspected leak type as determined at MRI of the spine is necessary to maximize the likelihood of a diagnostic study. The authors focus primarily on advanced CT myelographic techniques for leaks from dural tears and CSF venous fistulas. The importance of optimal patient positioning, typical and atypical appearances of the different leak types, and artifacts that can mimic a CSF leak are considered. ©RSNA, 2026 Supplemental material is available for this article. See the invited commentary by Madhavan in this issue.