Surgical Ligation of Spinal CSF-Venous Fistulas after Transvenous Embolization in Patients with Spontaneous Intracranial Hypotension

Abstract

A spinal CSF-venous fistula is an increasingly recognized type of CSF leak that causes spontaneous intracranial hypotension. The detection of these fistulas requires specialized imaging such as digital subtraction myelography or dynamic CT myelography, and several treatment options are available. A novel treatment for these CSF-venous fistulas consisting of transvenous embolization with the liquid embolic agent Onyx has been described recently, but some patients require further treatment if embolization fails. The purpose of this study was to evaluate the safety and effectiveness of surgery following transvenous embolization. In a series of 6 consecutive patients who underwent surgical ligation of the fistula after endovascular embolization, there were no surgical complications. Postoperatively, complete resolution of symptoms was reported by 5 of the 6 patients, and brain MR imaging findings of spontaneous intracranial hypotension resolved in all patients. This study suggests that surgical ligation of spontaneous spinal CSF-venous fistulas after endovascular embolization is effective and safe.

FIG 1.

Lateral decubitus DSMs showing 8 spontaneous spinal CSF-venous fistulas (arrows) in 6 patients. A, A right T8 fistula. B, A left T1 fistula. C, A left T8 fistula. D, A right T5 fistula. E, A left T7 fistula. F, A left T6 fistula. G, A left T11 fistula. H, A right T3 fistula. A and B and C and D, Bilateral fistulas in 2 patients. Multiple CSF-venous fistulas are found in about one-tenth of patients.

FIG 2.

Post-transvenous embolization CT scans (A–D) and an anterior-posterior radiograph (E) showing Onyx within the neural foramen in 4 patients (A–C and E) and just outside the neural foramen in 1 patient (D). The CT scan in B shows the results after surgical clip ligation following transvenous embolization.

FIG 3.

A and B, Pre-transvenous embolization lateral decubitus DSM and post-transvenous embolization lateral decubitus DSM showing a residual/recurrent CSF-venous fistula. Anterior-posterior post-transvenous embolization radiograph (C) shows the distribution of intravascular Onyx.

FIG 4.

Intraoperative photograph showing Onyx (arrows) within the epidural veins.