Role of CT myelography in the diagnosis and management of spontaneous intracranial hypotension

Abstract

Introduction: Spontaneous intracranial hypotension (SIH) is a secondary cause of headache. Its pathophysiology is complex, and relies mainly on the notion of a localized leak, and thus a loss of cerebrospinal fluid (CSF) in the spinal region. SIH is little known to the medical profession, for which CT myelography is a technique on the rise, allowing to identify and treat the leak using a blood-patch or a fibrin sealant. The aim of the study was to investigate the contribution of CT myelography in the diagnostic and therapeutic management of spontaneous intracranial hypotension, its modalities and population characteristics.

Material and methods: A cohort of patients with spontaneous intracranial hypotension who underwent a CT myelography in our department was retrospectively studied. Nineteen patients were included between March 2020 and October 2022.

Results: CT myelography allowed identification of an etiology in 16 patients (84 %). The etiology of the leak was mainly a dural tear, identified in 11 patients. One diverticulum and 4 CSF-venous fistulas were identified. First targeted injection of fibrin sealant allowed stopped the leak in 12 out of 17 patients.

Conclusion: CT myelography allows to identify the etiology of the CSF leak and pinpoint its topography. CT guidance can then be used to treat the leak in the same therapeutic timeframe, with greater efficacy during the first targeted injection of fibrin sealant. The current study data showed a high incidence of dural tears, and a significant proportion of venous-dural fistulas, and a low incidence of diverticulum.

Keywords: CSF leak; CT myelography; Fibrin sealant; Spontaneous intracranial hypotension.