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Research ArticleSPINE IMAGING AND SPINE IMAGE-GUIDED INTERVENTIONS

Assessing the Diagnostic Value of Brain White Matter Hyperintensities and Clinical Symptoms in Predicting the Detection of CSF-Venous Fistula in Patients with Suspected Spontaneous Intracranial Hypotension

Samantha L. Pisani Petrucci, Nadya Andonov, Peter Lennarson, Marius Birlea, Chantal O’Brien, Danielle Wilhour, Abigail Anderson, Jeffrey L. Bennett and Andrew L. Callen
American Journal of Neuroradiology April 2025, DOI: https://doi.org/10.3174/ajnr.A8548
Samantha L. Pisani Petrucci
aFrom the Department of Radiology (S.L.P.P., N.A., A.L.C.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Nadya Andonov
aFrom the Department of Radiology (S.L.P.P., N.A., A.L.C.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Peter Lennarson
bDepartment of Neurosurgery (P.L.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Marius Birlea
cDepartment of Neurology (M.B., C.O., D.W., A.A.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
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  • ORCID record for Marius Birlea
Chantal O’Brien
cDepartment of Neurology (M.B., C.O., D.W., A.A.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Danielle Wilhour
cDepartment of Neurology (M.B., C.O., D.W., A.A.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Abigail Anderson
cDepartment of Neurology (M.B., C.O., D.W., A.A.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Jeffrey L. Bennett
dDepartments of Neurology and Ophthalmology (J.L.B.), Programs in Neuroscience and Immunology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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  • ORCID record for Jeffrey L. Bennett
Andrew L. Callen
aFrom the Department of Radiology (S.L.P.P., N.A., A.L.C.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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  • FIG 1.
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    FIG 1.

    Illustrative examples of the classifications of FLAIR WMH. A, Patient with minimal punctate FLAIR hyperintensities without frontal predilection (arrows). B1, Patient with frontal-predominant migrainous-type WHM involving the subcortical and periventricular white matter (arrows; detailed inset B2), characteristically seen with migraines. C, Microangiopathic-type WMH with diffuse supratentorial lesions.

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    FIG 2.

    A, Bar graph illustrating the percentage of patients with patterns of WMH, which differed significantly between those with and without a myelographically-proved CVF (P = .005). B, Bar graph illustrating the frequency of myelographically-localized CVF in patients according to the pattern of WMH. There is an overall significant difference in CVF positivity across patterns of WMH (P = .006), with post hoc analyses demonstrating a significant difference between the minimal and migrainous WMH classes (*P = .002).

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    FIG 3.

    Bar graph illustrating the distribution of clinical symptoms and characteristics between patients with CVF+ and CVF– at presentation. Features identified via multivariate logistic regression to have a significant effect on the presence of CVF on dynamic CT myelography are denoted by positive (+) or negative (–) associations.

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    Table 1:

    Patient demographics and imaging characteristics

    CharacteristicCVF+ (n = 40)CVF– (n = 32)
    Mean age (range) (yr)61.6 (SD, 9.2) (34–83)58.2 (SD, 9.6) (22–71)
    Sex female (%)/male (%)23 (58%)/17 (42%)23 (72%)/9 (28%)
    Bern score
     Median (range; IQR)6 (1–9; 3)a1 (0–6; 2)
     Low probability 0–2 (%)1 (2.5%)28 (87.5%)
     Intermediate probability 3–4 (%)10 (25%)3 (9.4%)
     High probability 5–9 (%)29 (72.5%)1 (3.1%)
    WMH
     Mean total WMH (SD)7.9 (8.2)a20.7 (21.8)
     Mean frontal WMH (SD)5.4 (6.5)a14.6 (14.1)
     Median percentage frontal WMH (IQR)53.3 (52.2)70.6 (31.2)
    WMH pattern (No.) (%)
     Minimal22 (55%)10 (32.3%)
     Migrainous5 (12.5%)15 (46.9%)
     Microangiopathic13 (32.5%)7 (21.9%)
    • Note:—IQR indicates interquartile range.

    • ↵a Denotes P < .05 after Bonferroni adjustment. Patients with myelographically-proved CVF have higher Bern scores and fewer WMH. There is a strong correlation between the Bern score and CVF positivity (rpb = −0.82).

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    Table 2:

    The combined features of a low-probability Bern score and the presence of migrainous WMH resulted in the highest sensitivity, specificity, PPV, and NPV

    Features Predictive of CVF−SensitivitySpecificityPPVNPV
    Bern score <50.7250.9690.9670.738
    Bern score <30.9750.8750.9070.966
    Presence of the pattern of migrainous WMH0.9000.4690.6790.789
    Bern score <5 & presence of the pattern of migrainous WMH 0.65110.696
    Bern score <3 & presence of the pattern of migrainous WMH0.9750.9380.9510.968
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Samantha L. Pisani Petrucci, Nadya Andonov, Peter Lennarson, Marius Birlea, Chantal O’Brien, Danielle Wilhour, Abigail Anderson, Jeffrey L. Bennett, Andrew L. Callen
Assessing the Diagnostic Value of Brain White Matter Hyperintensities and Clinical Symptoms in Predicting the Detection of CSF-Venous Fistula in Patients with Suspected Spontaneous Intracranial Hypotension
American Journal of Neuroradiology Apr 2025, DOI: 10.3174/ajnr.A8548

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WMH and Symptoms Predict CSF Venous Fistulas
Samantha L. Pisani Petrucci, Nadya Andonov, Peter Lennarson, Marius Birlea, Chantal O’Brien, Danielle Wilhour, Abigail Anderson, Jeffrey L. Bennett, Andrew L. Callen
American Journal of Neuroradiology Apr 2025, DOI: 10.3174/ajnr.A8548
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