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Journal of Neurointerventional Surgery Nov 2023Cerebrospinal fluid (CSF)-venous fistulas (CVFs) are increasingly identified as a cause of spontaneous intracranial hypotension (SIH). Lateral decubitus digital...
Direct comparison of digital subtraction myelography versus CT myelography in lateral decubitus position: evaluation of diagnostic yield for cerebrospinal fluid-venous fistulas.
BACKGROUND
Cerebrospinal fluid (CSF)-venous fistulas (CVFs) are increasingly identified as a cause of spontaneous intracranial hypotension (SIH). Lateral decubitus digital subtraction myelography (LD-DSM) and CT myelography (LD-CTM) are mainly used for detection, but the most sensitive method is yet unknown.
OBJECTIVE
To compare LD-DSM with LD-CTM for diagnostic yield of CVFs.
METHODS
Patients with SIH diagnosed with a CVF between January 2021 and December 2022 in which the area of CVF(s) was covered by both diagnostic modalities were included. LD-CTM immediately followed LD-DSM without repositioning the spinal needle, and the second half of the contrast agent was injected at the CT scanner. Patients were awake or mildly sedated. Retrospectively, two neuroradiologists evaluated data independently and blinded for the presence of CVF.
RESULTS
Twenty patients underwent a total of 27 combined LD-DSM/LD-CTM examinations (4/20 with follow-up and 3/20 with bilateral examinations). Both raters identified significantly more CVFs with LD-CTM than with LD-DSM (rater 1: 39 vs 9, P<0.001; rater 2: 42 vs 12, P<0.001). Inter-rater agreement was substantial for LD-DSM (κ=0.732) and LD-CTM (κ=0.655). The results remained significant after considering the senior rating for cases of disagreement (39 vs 10; P<0.001), and no CVF detected on LD-DSM was missed on LD-CTM.
CONCLUSION
In this study, LD-CTM has a higher diagnostic yield for the detection of CVFs than LD-DSM and should supplement LD-DSM, but further studies are needed. LD-CTM can be easily acquired in awake or mildly sedated patients with the second half of contrast injected just before CT scanning, or it may be considered as a stand-alone investigation.
PubMed: 37918908
DOI: 10.1136/jnis-2023-020789 -
Operative Neurosurgery (Hagerstown, Md.) Apr 2024Spontaneous intracranial hypotension is recognized as a cause for refractory headache. Treatment can range from blind blood patch injection to microsurgical repair of...
BACKGROUND AND OBJECTIVES
Spontaneous intracranial hypotension is recognized as a cause for refractory headache. Treatment can range from blind blood patch injection to microsurgical repair of the cerebrospinal fluid (CSF) leak. The objective of the study was to investigate the safety and efficacy of the targeted blood patch injection (TBPI) technique through a mini-open approach in treatment of refractory intracranial hypotension.
METHODS
We retrospectively reviewed cases of 20 patients who were treated for spontaneous intracranial hypotension at our institute between 2011 and 2022. Head and spine MRI and whole-spine myelography were performed in an attempt to localize the CSF leak. All patients underwent implantation of two epidural drains above and beneath the index level through a minimally invasive interlaminar microsurgical approach under general anesthesia. Then, blood patch was injected under clinical surveillance. Treatment success and surgical complications were evaluated postoperatively and at follow-up.
RESULTS
Patients presented with orthostatic headache, vertigo, sensory deficits, and hypacusis (95%, 15%, 15%, and 10%, respectively). Subdural effusions were present in 65% of the cases. A CSF leak was identified in all patients. The exact site of the CSF leak could be identified in 80% of cases. TBPI was performed with an average blood amount of 37.5 mL. A significant improvement of symptoms was reported in 90% of the cases. A total of 15% of the patients showed recurrent symptoms and underwent a second TBPI, resulting in symptom relief. No therapy-related complications were reported.
CONCLUSION
TBPI is a safe and efficient treatment for spontaneous intracranial hypotension. It is performed in a minimally invasive procedure and can be repeated, if necessary, with a very low-risk profile.
Topics: Humans; Intracranial Hypotension; Blood Patch, Epidural; Retrospective Studies; Cerebrospinal Fluid Leak; Spine
PubMed: 37888978
DOI: 10.1227/ons.0000000000000974 -
AJNR. American Journal of Neuroradiology Nov 2023The likelihood of discovering a CSF leak can be determined by assessing intracranial abnormalities. However, the Dobrocky scoring system, which is used to determine this...
Likelihood of Discovering a CSF Leak Based on Intracranial MRI Findings in Patients without a Spinal Longitudinal Extradural Collection: A New Probabilistic Scoring System.
BACKGROUND AND PURPOSE
The likelihood of discovering a CSF leak can be determined by assessing intracranial abnormalities. However, the Dobrocky scoring system, which is used to determine this likelihood, did not incorporate patients with CSF-venous fistulas. This study sought to create a new probabilistic scoring system applicable to patients without a spinal longitudinal extradural collection.
MATERIALS AND METHODS
A retrospective review was completed of patients with suspected spontaneous intracranial hypotension who underwent brain MR imaging followed by digital subtraction myelography with same-day CT myelography. Patients with and without leaks found on digital subtraction myelography were included. MRIs were assessed for numerous reported stigmata of spontaneous intracranial hypotension and were compared between cohorts.
RESULTS
One hundred seventy-four patients were included; 113 (64.9%) were women (average age, 52.0 [SD, 14.3] years). A CSF leak was found in 98 (56.3%) patients, nearly all of which (93.9%) were CSF-venous fistulas. Diffuse dural enhancement, internal auditory canals dural enhancement, non-Chiari cerebellar descent, pituitary engorgement, brain sag, dural venous sinus engorgement, and decreased suprasellar cistern size were associated with a CSF leak. A probabilistic scoring system was made in which a single point value was assigned to each of those findings: 0-2 considered low probability and ≥3 considered intermediate-to-high probability of a CSF leak.
CONCLUSIONS
This study offers a new probabilistic scoring system for evaluating the likelihood of discovering a CSF leak on the basis of intracranial MR imaging findings, though the new system is not superior to that of the Dobrocky method for predicting the presence of CSF leaks.
Topics: Humans; Female; Middle Aged; Male; Intracranial Hypotension; Cerebrospinal Fluid Leak; Magnetic Resonance Imaging; Myelography; Fistula
PubMed: 37884301
DOI: 10.3174/ajnr.A8030 -
AJNR. American Journal of Neuroradiology Nov 2023We describe a novel patient-positioning device for dynamic CT myelography. Dynamic CT myelography requires angling the patient's spine to distribute dense contrast along...
We describe a novel patient-positioning device for dynamic CT myelography. Dynamic CT myelography requires angling the patient's spine to distribute dense contrast along the dependent thecal sac. The proposed device is constructed of a low-density reinforced polymer frame and can be raised or lowered to various heights with a hand-operated mechanism, allowing precise adjustment of the spinal angle and control of the contrast bolus, increasing the safety, reproducibility, and sensitivity of dynamic CT myelography.
Topics: Humans; Myelography; Reproducibility of Results; Spine; Tomography, X-Ray Computed
PubMed: 37827715
DOI: 10.3174/ajnr.A8023 -
Journal of Zoo and Wildlife Medicine :... Oct 2023Intervertebral disc disease (IVDD) in captive large felids is a commonly encountered syndrome that is usually treated medically, with surgical cases only sparsely...
Intervertebral disc disease (IVDD) in captive large felids is a commonly encountered syndrome that is usually treated medically, with surgical cases only sparsely documented in the literature. This case series describes the diagnosis, surgical treatment, and postoperative care of three cases of IVDD in large felids: an 8-yr-old male Bengal tiger () with acute paraplegia, a 10-yr-old male tiger of unknown subspecies () with progressive tetraparesis, and a 17-yr-old female African lion () with mild paraparesis. Two cases were diagnosed via magnetic resonance imaging (MRI) and the third was diagnosed with computed tomography myelography. Disc herniations were confirmed during surgery in all cases and via necropsy in two cases. Surgical procedures included a thoracolumbar dorsal hemilaminectomy in one tiger, a cervical hemilaminectomy in the other tiger, and a continuous lumbar dorsal hemilaminectomy in the lion. One tiger was euthanized approximately 1 wk after surgery and the other tiger was euthanized approximately 1 mon after surgery, following a lack of clinical improvement in both cases. The lion, however, improved markedly over several months after surgery before acutely declining secondary to spinal neoplasia. Analysis of these cases suggests that pursuing MRI and surgery as soon as possible after the onset of clinical signs and marking affected disc sites based on imaging to provide landmarks for the surgeon may improve long-term prognosis. Additionally, strict postoperative confinement in an accessible cage is beneficial to facilitate care and prevent overexertion while allowing early movement.
Topics: Male; Female; Animals; Intervertebral Disc Displacement; Panthera; Tigers; Lions; Felidae
PubMed: 37817629
DOI: 10.1638/2022-0138 -
Lakartidningen Oct 2023Spontaneous intracranial hypotension (SIH) is a disease presenting mostly with orthostatic head and neck pain due to a spontaneous cerebrospinal fluid (CSF) leak or a...
Spontaneous intracranial hypotension (SIH) is a disease presenting mostly with orthostatic head and neck pain due to a spontaneous cerebrospinal fluid (CSF) leak or a CSF-venous fistula in the spinal region. It demonstrates typical MRI findings with sagging of the brain causing tension of the meninges and sometimes the cranial nerves. It shares some clinical similarities with post puncture headache but differs in its pathophysiological cause, diagnosis, and treatment. Many patients remain misdiagnosed or wait too long for the correct diagnosis. The diagnostic work-up includes an MRI of the head and spine in search of typical SIH signs. Myelography and CT scans are performed to identify the location of the CSF leak or CSF-venous fistula. Treatment options may involve (1) initial conservative treatment with bed rest, caffein and fluids, (2) interventions such as epidural blood patch, fibrin patch, and embolization, or (3) surgical closure of the leak.
Topics: Humans; Intracranial Hypotension; Blood Patch, Epidural; Brain; Headache; Fistula
PubMed: 37782313
DOI: No ID Found -
Journal of the American Animal Hospital... Sep 2023Accurate diagnostic imaging is required for surgical planning of acute thoracolumbar intervertebral disc extrusion. However, data comparing the accuracy of conventional...
Accurate diagnostic imaging is required for surgical planning of acute thoracolumbar intervertebral disc extrusion. However, data comparing the accuracy of conventional IV contrast-injected computed tomography (CT) and myelography CT for hemilaminectomy localization and size assessment are sparse. In this study, IV contrast-injected CT and myelography CT were performed in 48 French bulldogs presenting with acute disc herniation and compared with postsurgical CT. CT images were evaluated by three raters. IV contrast-injected CT erroneously identified the compressive lesion site significantly more often than myelography CT. The length of the compressive lesion was significantly higher using myelography CT compared with conventional CT, but this did not lead to relevant consequences on the surgical opening site length. Myelography CT should therefore be recommended when thoracolumbar disc disease is suspected and multiple compressive lesions are visualized on IV-injected CT in French bulldogs.
Topics: Animals; Dogs; Intervertebral Disc Displacement; Myelography; Tomography, X-Ray Computed; Laminectomy; Intervertebral Disc; Dog Diseases
PubMed: 37708472
DOI: 10.5326/JAAHA-MS-7318 -
The Laryngoscope Feb 2024An adolescent male presented with orthostatic headaches following head trauma. MRI showed cerebellar tonsil displacement and a bony defect in the clival skull base.... (Review)
Review
An adolescent male presented with orthostatic headaches following head trauma. MRI showed cerebellar tonsil displacement and a bony defect in the clival skull base. Digital subtraction myelography (DSM) confirmed a cerebrospinal fluid-venous fistula (CVF). This was repaired endoscopically. CVFs cause uncontrolled flow of CSF into the venous system resulting in symptoms of intracranial hypotension. They're often difficult to identify on initial imaging. This is the first reported CVF originating in the central skull base, and the first treated via endoscopic trans-nasal approach. CVFs may elude initial imaging, making DSM crucial for unexplained spontaneous intracranial hypotension. Laryngoscope, 134:645-647, 2024.
Topics: Adolescent; Humans; Male; Cerebrospinal Fluid Leak; Intracranial Hypotension; Skull Base; Cranial Fossa, Posterior; Fistula
PubMed: 37681943
DOI: 10.1002/lary.31032 -
Interventional Neuroradiology : Journal... Aug 2023We present an updated ultrafast dynamic computed tomography myelography technique that can be used for the localization of spontaneous spinal cerebrospinal fluid leaks...
We present an updated ultrafast dynamic computed tomography myelography technique that can be used for the localization of spontaneous spinal cerebrospinal fluid leaks in the setting of spontaneous intracranial hypotension. This has over twice the temporal resolution of previously described techniques at the same radiation dose output.
PubMed: 37606552
DOI: 10.1177/15910199231193463