McRae-Posani Bala, Kim Andrew, Edasery David, Strauss Sara, Roytman Michelle, Park John K, Salama Gayle
Department of Radiology, Weill Cornell Medicine, New York, NY, USA.
Department of Radiology, Weill Cornell Medicine, New York, NY, USA.
Clin Neurol Neurosurg. 2025 Aug;255:108978. doi: 10.1016/j.clineuro.2025.108978. Epub 2025 May 23.
To report incidence, typology and treatment outcomes of spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH).
In this IRB approved study, consecutive SIH patients with myelogram-confirmed spinal CSF leak location, who underwent treatment between 2021 and 2023 at a single institution were retrospectively analyzed. The outcome variable was definitive treatment of SIH, defined as clinical and/or radiographic resolution of symptoms. Leak type classification was: Type 1 = ventral dural tear, Type 2 = lateral dural nerve root sleeve tear, Type 3 = CSF-venous fistula (CVF).
32 SIH patients (average age 48 ± 15, 28 % male, 72 % female) were analyzed. A majority of them had a Type 1 CSF leak (59 %), followed by Type 3 (31 %) and Type 2 (9 %) leaks. Thoracic spine was the predominant location of the leaks (84 %); notably all CSF-venous fistulas were located there. Following trials of conservative management, all patients underwent treatment with EBP after leak site localization. 22/32 patients (69 %) had at least some resolution of symptoms following the first EBP. For 2/32 (6 %, both Type 2 leak), one targeted EBP provided definitive treatment. 30/32 (94 %, all leak types) had persistent clinical symptoms and had additional EBP(s). The mean number of EBPs per patient was 1.4 (range = 1-3). Following treatment failure of EBP(s), 10 patients with Type 3 leaks had transvenous embolization, which resulted in definitive treatment for 9 (90 %); 16 patients (leak Type 1 = 15, Type 2 = 1) had open dural surgery, which resulted in definitive treatment for 15 (94 %, all Type 1 leaks).
Overall, our analysis is consistent with recent data demonstrating that SIH incidence is higher among female patients and that CVFs are slightly more prevalent than previously reported, seen in nearly a third of our patients. Thoracic spine is the predominant location of CSF leaks; all our CVFs were located there. On treatment modalities, while EBP remains an important tool offering immediate symptom relief to SIH patients in the short term, permanent closure of the CSF leak and complete resolution of symptoms is rarely achieved with EBP. Definitive treatment is more likely with targeted endovascular and surgical modalities.
报告自发性颅内低压（SIH）患者脊髓脑脊液漏的发生率、类型及治疗结果。
在这项经机构审查委员会批准的研究中，对2021年至2023年在单一机构接受治疗、经脊髓造影证实脊髓脑脊液漏位置的连续性SIH患者进行回顾性分析。结果变量为SIH的确定性治疗，定义为症状的临床和/或影像学缓解。漏口类型分类为：1型=腹侧硬脑膜撕裂，2型=外侧硬脑膜神经根袖撕裂，3型=脑脊液-静脉瘘（CVF）。
分析了32例SIH患者（平均年龄48±15岁，男性占28%，女性占72%）。其中大多数为1型脑脊液漏（59%），其次是3型（31%）和2型（9%）漏口。胸椎是漏口的主要部位（84%）；值得注意的是，所有脑脊液-静脉瘘均位于此处。在保守治疗试验后，所有患者在确定漏口位置后接受了硬膜外血贴治疗（EBP）。22/32例患者（69%）在首次EBP后症状至少有部分缓解。对于2/32例（6%，均为2型漏口）患者，一次靶向EBP提供了确定性治疗。30/32例（94%，所有漏口类型）有持续临床症状并接受了额外的EBP治疗。每位患者EBP的平均次数为1.4次（范围=1 - 3次）。在EBP治疗失败后，10例3型漏口患者进行了经静脉栓塞，其中9例（90%）获得了确定性治疗；16例患者（1型漏口15例，2型漏口1例）进行了开放性硬脑膜手术，其中15例（94%，均为1型漏口）获得了确定性治疗。
总体而言，我们的分析与近期数据一致，表明女性患者中SIH发病率较高，且CVF比先前报道的略为常见，在近三分之一的患者中可见。胸椎是脑脊液漏的主要部位；我们所有的CVF均位于此处。关于治疗方式，虽然EBP仍然是在短期内为SIH患者提供即时症状缓解的重要工具，但通过EBP很少能实现脑脊液漏的永久性闭合和症状的完全缓解。靶向血管内和手术方式更有可能实现确定性治疗。
