Atormac
briv
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 6295  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (912 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
   References
   Article Figures

 Article Access Statistics
    Viewed6202    
    Printed76    
    Emailed3    
    PDF Downloaded69    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 4  |  Page : 439-441

Spontaneous intracranial hypotension: Detection of presumed site of spinal leak using T2 FIESTA MR imaging


Department of Radiology, St. John's Medical College Hospital, Bangalore, India

Date of Web Publication6-Sep-2012

Correspondence Address:
Anisha S Tandon
Department of Radiology, St. John's Medical College Hospital, Bangalore
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.100728

Rights and Permissions



How to cite this article:
Tandon AS, Sinha N. Spontaneous intracranial hypotension: Detection of presumed site of spinal leak using T2 FIESTA MR imaging. Neurol India 2012;60:439-41

How to cite this URL:
Tandon AS, Sinha N. Spontaneous intracranial hypotension: Detection of presumed site of spinal leak using T2 FIESTA MR imaging. Neurol India [serial online] 2012 [cited 2021 Jul 30];60:439-41. Available from: https://www.neurologyindia.com/text.asp?2012/60/4/439/100728


Sir,

Spontaneous intracranial hypotension (SIH) is thought to result from an occult cerebrospinal fluid (CSF) leak, [1] resulting in decreased CSF volume and pressure. Although the cranial and spinal magnetic resonance imaging (MRI) findings have been well documented, there has been only brief mention of predicting the site of leak on non-invasive MR imaging. We report the benefit of 3D Fast Imaging Employing Steady State Acquisition (3D FIESTA) MR imaging of the spine to document the possible site of CSF leak.

A 32-year-old man presented with one-month history of progressively worsening orthostatic headache, worsening as the day progressed. He also complained of dizziness, blurred vision, and nausea. There was no history of trauma or fever and the physical and neurological examination was normal. Intracranial MRI revealed diffuse thickening and enhancement of pachymeninges, bihemispheric subdural hygromas [Figure 1] and [Figure 2], sagging brainstem [Figure 1] and [Figure 3], and an increase in the mean height of pituitary [Figure 3]. Sagittal and axial T2 FIESTA of the cervicodorsal spine revealed an anterior extradural fluid collection [Figure 4] and [Figure 5] with prominent nerve root sleeves from C4-5 to C7-D1 levels, the latter most prominent on the left side at C5-6 level [Figure 6]. On the basis of these findings, we concluded that a cervicodorsal spinal CSF leak was responsible for the SIH and the possible site of leak was at the C5-6 level. He was subsequently treated with an autologous epidural blood patch injected in the lumbar region which failed to relieve his symptoms. In light of the spinal MR findings, a repeat epidural blood patch performed at the lower cervical level resulted in significant resolution of his symptoms.
Figure 1: Coronal T2W MRI shows bihemispheric subdural hygromas (white arrows)

Click here to view
Figure 2: Axial contrast enhanced T1W MRI shows diffuse bilateral leptomeningeal enhancement (white arrows)

Click here to view
Figure 3: Sagittal contrast enhanced T1W MRI shows leptomeningeal enhancement and increased height of the pituitary gland (white arrow)

Click here to view
Figure 4: Sagittal 3D FIESTA of the cervicodorsal spine shows an anterior epidural CSF collection (white arrows)

Click here to view
Figure 5: Axial 3D FIESTA of the cervical spine shows an anterior epidural CSF collection (white arrow)

Click here to view
Figure 6: Axial 3D FIESTA of the cervical spine shows dilated left C5-6 nerve root sleeve (white arrow)

Click here to view


SIH is defined as a syndrome of reduced CSF pressure that occurs in the absence of dural puncture, surgery, or trauma. [1],[2],[3] The pathogenesis is usually considered to be an occult CSF leak through small defects in the meninges with a resultant decrease in CSF volume and pressure. [2],[3] The diagnostic intracranial imaging findings of SIH include subdural fluid collection, descent of the cerebellar tonsils, brainstem sagging, enlargement of the pituitary gland, and diffuse, intense pachymeningeal enhancement. [1],[2],[3] Spinal MRI abnormalities described in literature include distention of the epidural veins, epidural fluid collection, and abnormal visualization of the nerve root sleeves. [1],[2],[3],[4] In a case of SIH described by Rando and Fishman, [5] the patient had a leak at the C7-T1 level on radionuclide cisternography, which corresponded to MR findings of dilated nerve root sleeves, thought to be the site of CSF leakage. Our patient had classic cranial MR findings of SIH, with spinal MRI showing a large anterior cervicodorsal level epidural fluid collection with dilated nerve root sleeves from C4-5 to C7-D1 levels, maximally present at the left C5-6 level suggesting this region to be the site of leak. Relief of symptoms on treatment with epidural blood patch injected at the lower cervical level provided diagnostic confirmation of the possible site of leak. This patient highlights the importance of the 3D FIESTA sequence during spinal MR imaging to diagnose the site of CSF leak in cases of SIH. This non-invasive technique will alert the astute radiologist to subtle findings such as epidural fluid collections and distended nerve root sleeves which will enable predicting the level of spontaneous CSF leak.

 
  References Top

1.Rabin MR, Roychowdhury S, Meyer JR, Cohen BA, LaPat KD, Russell EJ. Spontaneous intracranial hypotension: Spinal MR findings. AJNR Am J Neuroradiol 1998;19:1034-9.  Back to cited text no. 1
    
2.Fishman R, Dillon D. Dural enhancement and cerebral displacement secondary to intracranial hypotension. Neurology 1993;43:609-11.  Back to cited text no. 2
    
3.Watanabea A, Horikoshia T, Uchidaa M, Koizumi H, Yagishita T, Kinouchi H. Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neuroradiol 2009;30:147-51.  Back to cited text no. 3
    
4.Medina JH, Abrams K, Falcone S, Bhatia RG. Spinal imaging findings in spontaneous intracranial hypotension. AJR Am J Roentjenol 2010;195:459-64.  Back to cited text no. 4
    
5.Rando T, Fishman R. Spontaneous intracranial hypotension: Report of two cases and review of the literature. Neurology 1992;42(3 Pt 1):481-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow