A Novel Endovascular Therapy for CSF Hypotension Secondary to CSF-Venous Fistulas

Abstract

We report a consecutive case series of patients who underwent transvenous embolization of the paraspinal vein, which was draining the CSF-venous fistula, for treatment of spontaneous intracranial hypotension. These are the first-ever reported cases of this treatment for CSF-venous fistulas. All patients underwent spinal venography following catheterization of the azygous vein and then selective catheterization of the paraspinal vein followed by embolization of the vein with Onyx. All patients had improvement of clinical and radiologic findings with 4 patients having complete resolution of headaches and 1 patient having 50% reduction in headache symptoms. Pachymeningeal enhancement resolved in 4 patients and improved but did not resolve in 1 patient. Brain sag resolved in 4 patients and improved but did not resolve in 1 patient. There were no cases of permanent neurologic complications. All patients were discharged home on the day of the procedure.

FIG 1.

Examples of CSF-venous fistulas from the 5 patients. A, CSF-venous fistula at the right T8 in patient 1 with contrast in the paraspinal vein (blue arrow). B, CSF-venous fistula at the right T4 in patient 2 with contrast in the paraspinal vein (blue arrows). C, CSF-venous fistula at the right T7 in patient 3 with contrast in the paraspinal vein (blue arrows). D, Large CSF-venous fistula in patient 4 with complete opacification of the right T4 paraspinal vein (blue arrow). E and F, Bilateral CSF-venous fistulas at T9 in patient 5 (blue arrows).

FIG 2.

Steps involved in CSF-venous fistula embolization (patient 5). A, The azygous vein is selectively catheterized using a 5F Vertebral catheter. The catheter is directed posteriorly to face the azygous vein. In this case, the patient had to take a shallow inspiration to open up the valve between the azygous vein and the superior vena cava. B, The catheter is then advanced into the azygous vein over a stiff Glidewire. This support is needed for the catheter to make the 180° turn. C, This patient had bilateral CSF-venous fistulas at the right T9. We advanced a Headway Duo microcatheter into the right T9 paraspinal vein, and a venogram was performed. The same procedure was performed for the left T9 paraspinal vein (D). E, Both veins are embolized with Onyx 34 to build a plug followed by Onyx 18. F, Postoperative CT shows excellent filling of the radicular veins at T9 bilaterally, essentially sealing off the CSF-venous fistulas.

FIG 3.

Pre- and posttreatment sagittal T1-weighted MRIs in patients 1–5. Patient 1 had a decreased mamillopontine distance, effacement of the prepontine and supracellar cistern, tonsillar descent, and engorgement of the pituitary gland. Following embolization, there was normalization of the suprasellar cistern and mamillopontine cistern distances as well as the prepontine cistern and resolution of tonsillar ectopia. Pituitary engorgement improved as well. Patient 2 had prepontine and suprasellar cistern effacement and decreased mamillopontine distance and tonsillar ectopia. Following embolization, these all resolved. Note the incidental pituitary cyst. Patient 3 had decreased mamilopontine distance and effacement of the suprasellar cistern and prepontine cistern, all of which normalized postembolization. Patient 4 had effacement of the suprasellar cistern and prepontine cistern and decreased mamillopontine distance, all of which resolved on follow-up MR imaging. Patient 5 had effacement of the suprasellar cistern and prepontine cistern. There was still suprasellar cistern effacement on posttreatment MR imaging, but the prepontine cistern distance normalized. Pt indicates patient; Pre, pretreatment; Post, postreatment.

FIG 4.

Pre- and posttreatment postcontrast T1-weighted MRIs in patients 1–5. Pretreatment MRIs show diffuse pachymeningeal enhancement in all 5 patients. Posttreatment, there is complete resolution of pachymeningeal enhancement in patients 1, 2, 4, and 5, with subtle pachymeningeal enhancement in patient 3. Pt indicates patient; Pre, pretreatment; Post, postreatment.