Application of time-spatial labeling inversion pulse magnetic resonance imaging in the diagnosis of spontaneous intracranial hypotension due to high-flow cerebrospinal fluid leakage at C1-2

Abstract

Background: Spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid (CSF) leakage at C1-2 poses diagnostic and therapeutic challenges to spine surgeons. Although computed tomography (CT) myelography has been the diagnostic imaging modality of choice for identifying the CSF leakage point, extradural CSF collection at C1-2 on conventional CT myelography or magnetic resonance imaging (MRI) may often be a false localizing sign.

Case description: The present study reports the successful application of time-spatial labeling inversion pulse (T-SLIP) MRI, which enabled the precise identification of the CSF leakage point at C1-2 in a 28-year-old woman with intractable SIH. After identifying the leakage point using both CT myelography and T-SLIP MRI, surgery was performed to seal the CSF leak. Intraoperatively, a pouch suggestive of an extradural arachnoid cyst around the left C2 nerve root was found, which was repaired by packing the pouch with muscle and fibrin glue. Clinical improvement was observed shortly after surgery, and postoperative imaging revealed the disappearance of the CSF leakage.

Conclusions: T-SLIP MRI may provide useful information on the flow dynamics of CSF in SIH patients due to high-flow leakage. However, further experience is required to assess its sensitivity and specificity as an imaging modality for identifying CSF leakage points.

Keywords: C1-2; CT myelography; cerebrospinal fluid leakage; spontaneous intracranial hypotension; time-spatial labeling inversion pulse (T-SLIP) MRI.

Figure 1

(a) Magnetic resonance imaging (MRI) of the cervical spine (T2-weighted sagittal image) obtained shortly following neck injury, which was considered within the normal range. (b) MRI of the cervical spine (T2-weighted sagittal image) at the time of admission, showing decreased cerebrospinal fluid (CSF) space. The increase in the thickness of the retro-odontoid tissue was also noted (asterisk). (c) Heavily T2-weighted MRI showing the accumulation of extradural CSF in the paraspinal tissue at C1-2 (arrow)

Figure 2

Computed tomography myelogram obtained following admission, showing massive leakage of contrast medium at C1-2 of the left side (a, axial view; b, sagittal view). At two weeks post-surgery, no leakage of contrast medium was observed (c, axial view; d, sagittal view)

Figure 3

Time-spatial labeling inversion pulse MRI showing the CSF flow dynamics. a/c, axial view; b/d, sagittal view. Compared with a/b, CSF leakage was observed in the C1-2 epidural space (circled) in c/d (c/d scanned 2.7 seconds after a/b)