Supine Digital Subtraction Myelography for the Demonstration of a Dorsal Cerebrospinal Fluid Leak in a Patient with Spontaneous Intracranial Hypotension: A Technical Note

摘要

A patient with spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak required localization of the leakage site prior to surgical management. Conventional, computed tomography and prone digital subtraction myelography failed to localize the dural tear, which was postulated to be dorsally located. We present here a digital subtraction myelographic approach to accurately localize a dorsal site of CSF leakage by injecting iodinated contrast via a lumbar drain with the patient in the supine position. Keywords: Spontaneous intracranial hypotension, digital subtraction myelography, CSF leakCASE REPORTA 34 year-old male presented to the emergency department at our institution approximately one week following the sudden onset of headache and acute neck pain. This was accompanied by nausea, vomiting, photophobia, diplopia and bilateral tinnitis. The pain was described as constant and rated as 5/10 (verbal) at the time of presentation and 8/10 (verbal) at its worst. Symptoms were exacerbated by sitting and palliated by both walking and approximately 30 minutes of supine positioning. Coughing and sneezing were also identified as aggravating factors. The temporal course was one of less pain upon arising followed by progressive worsening throughout the day. There was no associated history of loss of conscious, facial numbness or tingling, fever or sweating. The patient denied any history of rhinorrhea or otorrhea. No prior back surgery, trauma, lumbar puncture or similar headaches were reported.Initial clinical exam revealed a normal, pain free cervical range of active motion with an unremarkable neurological examination. An atraumatic lumbar puncture performed in the Emergency Department revealed mildly elevated protein and normal glucose and red and white blood cell counts. A gram stain and culture documented sterile CSF. Unfortunately, opening CSF pressure was not recorded.Initial CT head demonstrated no abnormal findings. MR imaging of the head and cervical spine revealed diffuse thickening and enhancement of the pachymeninges with flattening of the anterior pons and low lying cerebellar tonsils (Figure 1). The venous hinge angle was reduced to 70 degrees (Figure 2). A nuclear medicine CSF circulation study revealed no evidence of CSF leakage (Figure 3). Open in a separate windowFigure 1 34 year old male patient with spontaneous intracranial hypotension and dorsal cerebrospinal fluid leak. A. Sagittal midline T1-weighted MRI (1.5 Tesla magnet; TR, 517 msec; TE, 9 msec; 7.7 ml Magnevist) contrast enhanced image of the head demonstrates caudal displacement of the cerebellar tonsils (short arrow) and slight flattening of the anterior pons (thick arrow) and decreased mammilopontine distance (long thin arrow). B. Coronal T1-weighted MRI (1.5 Tesla magnet; TR, 517 msec; TE, 9 msec; 7.7 ml Magnevist) contrast enhanced image shows diffuse pachymeningeal enhancement (arrowheads).