Modified Dynamic CT Myelography for Type 1 and 2 CSF Leaks: A Procedural Approach

Detection of type 1 CSF leak with modified dynamic CTM in 2 scan acquisitions. A, Coronal contrast-enhanced fat-suppressed T1-weighted image shows dural enhancement (arrows) consistent with spontaneous intracranial hypotension. B, Axial fat-suppressed T2-weighted image shows ventral and dorsal extradural fluid (arrows) consistent with a CSF leak. C, Sagittal image from dynamic CTM after 3 mL of intrathecal iodinated contrast shows coating of the entire ventral spine, with a transition point at the T1–T2 level (arrow). D, Sagittal image from dynamic CTM after additional injection of 2 mL of contrast and scanning of the cervicothoracic junction only confirms a leak at the T1–T2 level, where there is a split in the contrast column (arrow) and extradural contrast layering dependently with gravity in the cervical spine (arrowheads). E, Axial image from the dynamic CTM shows that the CSF leak (arrowheads) is secondary to a ventral midline calcified disc (arrow).

Detection of type 1 CSF leak with traditional dynamic CTM in 3 scan acquisitions. A–C, Sagittal images from 3 successive acquisitions of the total spine dynamic CTM show a split of contrast at the T1–T2 level with contrast accumulating in the ventral extradural space (arrows). This was first evident on the first acquisition, and the leak site can be determined with this acquisition alone. The second and third acquisitions show slightly more contrast accumulation in the extradural space. D, Axial image of the first acquisition of the dynamic CTM shows a calcified disc (arrowhead) splitting the contrast within the subarachnoid space (arrows).