Madhavan Ajay A, Carlton Jones Lalani, Kodet Michelle L, Cagnazzo Federico, Lutzen Niklas
From the Department of Radiology (A.A.M., M.L.K.), Mayo Clinic, Rochester, MN, USA; Department of Radiology (L.CJ.), Guys & St Thomas's and Kings College Hospitals NHS Foundation Trusts, London, UK and Department of Radiology (L.CJ.), IOPPN, Kings College London; Department of Radiology (F.C.), University Hospital of Montpellier, Montpellier, France and Department of Neuroradiology (N.L.), Medical Center, Faculty of Medicine, University of Freiburg, Germany.
AJNR Am J Neuroradiol. 2025 Aug 28. doi: 10.3174/ajnr.A8966.
CSF-venous fistulas are a common and increasingly recognized cause of spontaneous intracranial hypotension. Most CSF-venous fistulas occur in the thoracic spine and usually arise from nerve root sleeve diverticula. Myelography in the lateral decubitus position is necessary to detect and localize these fistulas, because this technique maximizes contrast density within diverticula, thereby permitting visualization of draining veins. Many modifications to decubitus myelography have been employed in an attempt to improve conspicuity of CSF-venous fistulas. In theory, maximizing the subarachnoid-venous pressure gradient during imaging should increase contrast flow through CSF-venous fistulas, improving detection of these sometimes-subtle leaks. Augmentation of intrathecal pressure through saline injection prior to myelography is a simple technique to achieve this and is common in many practices. However, only one prior case report has demonstrated the impact of pressurization on the visualization of a CSF-venous fistula. In this multi-institutional, retrospective case series, we report on a larger cohort of patients in whom CSF-venous fistulas were either occult or non-definite on myelography without saline pressurization and subsequently definitely seen on myelography with saline pressurization. While our study design precludes determining the incremental yield of saline infusion, it nonetheless provides further support of the value of saline pressurization during myelography in patients with suspected CSF-venous fistulas.ABBREVIATIONS: CB-CTM = cone beam CT myelogram; CVF = CSF-venous fistula; DSM = digital subtraction myelogram; EID-CTM = energy integrating detector CT myelogram; PCD-CTM = photon counting detector CT myelogram.
脑脊液-静脉瘘是自发性颅内低压常见且日益被认识到的病因。大多数脑脊液-静脉瘘发生在胸椎，通常起源于神经根袖憩室。侧卧位脊髓造影对于检测和定位这些瘘管是必要的，因为这种技术能使憩室内的造影剂密度最大化，从而使引流静脉显影。为了提高脑脊液-静脉瘘的显影效果，人们对卧位脊髓造影进行了许多改进。理论上，在成像过程中最大化蛛网膜-静脉压力梯度应能增加通过脑脊液-静脉瘘的造影剂流量，改善对这些有时很细微的漏口的检测。在脊髓造影前通过注射盐水增加鞘内压力是实现这一目的的一种简单技术，在许多医疗实践中很常见。然而，之前仅有一篇病例报告展示了加压对脑脊液-静脉瘘显影的影响。在这个多机构回顾性病例系列中，我们报告了一组更大的患者队列，这些患者的脑脊液-静脉瘘在未进行盐水加压的脊髓造影中隐匿或不明确，而在进行盐水加压的脊髓造影中后来明确可见。虽然我们的研究设计无法确定盐水输注的额外检出率，但它仍然进一步支持了在怀疑有脑脊液-静脉瘘的患者进行脊髓造影时盐水加压的价值。
CB-CTM = 锥束CT脊髓造影；CVF = 脑脊液-静脉瘘；DSM = 数字减影脊髓造影；EID-CTM = 能量积分探测器CT脊髓造影；PCD-CTM = 光子计数探测器CT脊髓造影
