Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences

Multiplanar reconstruction of 3D T2WI FS sequence showing a large nerve root diverticulum, which demonstrated a leakage on conventional dynamic myelography (not shown).

A 57-year-old woman with orthostatic headache and tinnitus. A, The sagittal, T2-weighted sequence demonstrates extensive extrathecal CSF and multiple suspicious disc protrusions (black arrowheads). B–D, Conventional dynamic myelography demonstrates a CSF leak at the T10/11 level with progressive contrast media distribution (arrowheads). Even in retrospect, the MR imaging did not demonstrate any suspicious lesion at the corresponding level (A, white arrowhead). The leak was confirmed intraoperatively and surgically closed. The follow-up spine MR imaging did not show any residual epidural CSF collection (not shown).

Sensitivity and specificity for the 3 different sequences with corresponding confidence intervals. T2WI indicates T2-weighted; 3D T2WI FS, 3D, isotropic, T2-weighted sequence with fat saturation; and T1WI Gd FS, isotropic, T1-weighted sequence with fat saturation after intrathecal application of gadolinium.

Scatterplots showing the accuracy of each sequence compared with the true location. T2-weighted (A); 3D T2WI FS, 3D T2-weighted sequence with fat saturation (B); and T1WI GD (C). On the x-axis is the location as reported by the readers. On the y-axis is the true location as found intraoperatively, −57 of 70 (81%); or as determined with multimodal imaging in conservatively managed patients −13 of 70 (19%). Patients in whom the leak has been correctly localized based on the corresponding MR image lie on the reference line.