Original Research Article

Spontaneous intracranial hypotension due to CSF–venous fistula: Evaluation of renal accumulation of contrast following decubitus myelography and maintained decubitus CT to improve fistula localization

This retrospective study evaluated a strategy combining sequential lateral decubitus digital subtraction myelography (LDDSM) and lateral decubitus CT (LDCT) to localize cerebrospinal fluid–venous fistulas (CVFs) in patients with suspected CSF leak. Twenty-two patients were included, all of whom underwent consecutive LDDSM and LDCT. If CVF was not visualized on the initial side, contralateral imaging was performed. A renal pelvis contrast score (RPCS), measured in Hounsfield units (HU), was used to assess contrast accumulation. CVFs were successfully identified in 21 of 22 patients (95%). The average RPCS on the CVF-positive side was 146 HU, while the contralateral negative side averaged 51 HU. In three cases, a third LDDSM repeated on the side with higher RPCS revealed the CVF after initial imaging failed. This approach may enhance CVF detection and improve diagnostic yield, supporting its further investigation in clinical practice.

Impression: Precise diagnosis is key in managing cerebrospinal fluid–venous fistulas (CVFs), and this study presents a promising technique. The sequential use of LDDSM and LDCT, combined with renal pelvis contrast scoring, may enhance CVF localization even in challenging cases. Though further validation is needed, this approach offers a potentially valuable diagnostic tool for improving outcomes in patients with spontaneous intracranial hypotension.

From Division of Neuroradiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto Western Hospital, New East Wing 3MC-430, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada.

View at: https://doi.org/10.1177/15910199231172627

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