Gadolinium-Enhanced MR Cisternography to Evaluate Dural Leaks in Intracranial Hypotension Syndrome

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Fig 1.
Axial T1-weighted fat-saturated MR image shows a right-sided CSF leak at the cervicothoracic junction extending into the right paraspinal soft tissue (arrows) and epidural collection (arrowhead).
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Fig 2.
Coronal (A) and axial (B and C) T1-weighted fat-saturated MR images reveal diffuse epidural (arrowhead) and paravertebral contrast accumulation (arrows) at the thoracolumbar area.
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Fig 3.
Coronal and sagittal T1-weighted fat-saturated MR images show multiple bilateral meningeal diverticula (arrows) at the thoracic and lumbar level.
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Fig 4.
A, Axial CT cisternography image shows right meningeal diverticulum (arrow) without CSF leak at the level of L1. B, Axial T1-weighted fat-saturated MR image reveals both a CSF leak on the right side (arrowheads) and a right meningeal diverticulum (arrow).

Table 1:

The diagnostic criteria for SIH proposed by Headache³ Classification Subcommittee of the International Headache Society

Diffuse and/or dull headache that worsens within 15 minutes after sitting or standing, with at least 1 of the following and fulfilling criterion:

At least 1 of the following:

Evidence of low CSF pressure on MR imaging (eg, pachymeningeal enhancement)
Evidence of CSF leakage on conventional myelography, CT myelography, or cisternography
CSF opening pressure <60 mm H₂O in sitting position

No history of dural puncture or other cause of CSF fistula

Headache resolves within 72 hours after epidural blood patching

Table 2:

Summary of diagnostic features in 19 patients with a diagnosis of SIH

Patient No.	Cranial MR Imaging	Spinal MR Imaging	CSF Pressure	CT Myelography or RC	Dural Puncture or Other Causes	Response to EBP (Immediate Relief^*)
1	−	+	N	−	−	+
2	+	−	↓	−	−	+
3	+	−	0	−	−	+
4	+	−	0	−	−	+
5	+	−	↓	−	−	+
6	+	−	↓	−	−	+
7	+	−	↓	−	−	+
8	+	−	↓	−	−	+
9	+	+	↓	−	−	+
10	+	−	↓	−	−	+
11	+	−	↓	−	−	+
12	−	+	N	+	−	+
13	+	−	↓	−	−	+
14	+	−	↓	−	−	+
15	+	−	0	−	−	+
16	+	−	↓	−	−	+
17	+	+	↓	+	−	+
18	+	+	↓	−	−	+
19	+	−	↓	−	−	+

Note:—SIH indicates spontaneous intracranial hypotension; RC, radionuclide cisternography; EBP, epidural blood patch; N, normal; ↓, low; +, yes; −, no.
* Immediate relief means that the patient symptoms resolve due to the pressure effect of EBP. This does not address complete cure of the disease.

Table 3:

Summary of MR cisternography findings of 19 patients with diagnosis of SIH

Patient No.	CSF Leak	Exact Location of CSF Leak	No. of the Dural Tear	Location of CSF Leak	Epidural Collection	Paravertebral Collection	Meningeal Diverticulum	Associated Findings
1	+	+	Single	Right T12	+	+	−	−
2	−	−	−	−	−	−	+	−
3	+	Diffuse	?	Bilateral T11-12 and L1-2	+	+	−	−
4	+	Diffuse	?	Bilateral T10-11-12 and L1-2-3	+	+	+	−
5	+	+	Single	Left T1	+	+	−	−
6	+	+	Single	C6 anteriorly	+	+	+	Cervical osteophyte and hernia
7	+	+	Multiple	Bilateral C7 and T1	+	+	+	−
8	+	+	Single	Right T10	+	+	−	−
9	+	+	Single	Right T2	+	+	−	−
10	+	+	Single	Left L2	−	+	+	−
11	+	+	Multiple	Bilateral C7 and T5	+	+	+	Thoracic osteophyte and hernia
12	+	+	Single	Right L1	−	+	+	−
13	+	+	Single	Left T4	+	+	+	−
14	+	+	Multiple	Bilateral T4-T5	−	+	+	−
15	+	+	Single	Bilateral T7	+	+	−	−
16	+	Diffuse	?	Bilateral T11-T12 and Left T9-T10	+	+	−	Prominent epidural veins
17	−	−	−	−	−	−	+	−
18	+	+	Multiple	Bilateral T2-T3 and Bilateral T11-T12	+	+	−	−

Note:—SIH indicates spontaneous intracranial hypotension; C, cervical; T, thoracic; L, lumbar; ?, not detected due to diffuse CSF leakage; +, yes; −, no.