Publication abstracts about spinal CSF leak from 2025

AUTHORS: Linda D’Antona, Sanjay Cheema, Dwij Mehta, Fion Bremner, Laurence Dale Watkins, Ahmed Kassem Toma, Manjit Singh Matharu

CITATION: The journal of headache and pain, 26(1), 27. https://doi.org/10.1186/s10194-024-01928-7

🔓 Open access! Full study available here.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a debilitating disorder, with an estimated annual incidence of 3.7 per 100,000. Diagnosing SIH can be challenging for clinicians, as patients frequently present with normal investigation findings. Intracranial pressure (ICP) monitoring has been proposed as a valuable tool for patients with orthostatic headaches that are highly suggestive of SIH but have inconclusive investigation results. The primary objective of this study was to determine the proportion of patients with spontaneous orthostatic headaches and normal diagnostic work-up who exhibited abnormal ICP monitoring results.

METHODS: This single-centre, retrospective observational study was conducted at a tertiary referral centre specialising in SIH and CSF dynamics disorders. Consecutive patients with spontaneous orthostatic headaches and inconclusive diagnostic work-up who underwent 24-hour ICP monitoring were considered eligible. The 24-hour ICP monitoring followed a standardised protocol, measuring median ICP and pulse amplitude (a marker of brain compliance) during the daytime, nighttime, and over the entire 24-hour period. Specific cut-offs for low and high ICP states were predetermined based on the best available current evidence.

RESULTS: Thirty-eight patients (23 females, mean age 41 years ± 14SD) were identified. All patients had orthostatic headaches with a spontaneous onset. The mean duration of symptoms was 46 months ± 36SD. ICP monitoring identified 3 patients (7.9%) with low ICP (mean of the median 24-hour ICP – 2 mmHg ± 2SD) and 6 patients (15.8%) with high ICP (mean of the median 24-hour ICP 9 mmHg ± 3SD). Obvious CSF dynamics disturbances were excluded in the remaining 29 patients (76.3%, mean of the median 24-hour ICP 3 mmHg ± 3SD). The only clinical feature that was more common in patients with abnormal ICP compared to patients with normal ICP results was audiovestibular disturbance, namely aural fullness or muffled hearing (67% versus 17%, p = 0.015). There were no complications from the ICP monitoring procedure for any patient.

CONCLUSIONS: When appropriately selected, patients with a clinical picture highly suggestive of SIH, who have a negative diagnostic work-up, may benefit from consideration of invasive ICP monitoring. Moreover, a significant minority of patients with orthostatic headache may paradoxically have a high CSF pressure state, which can be detected using ICP monitoring.

MEETING PRESENTATIONS: Portions of this work were presented in abstract and oral presentation form at the Twenty-eighth Anglo-Dutch Migraine Association meeting (08/06/2018), the Tenth Meeting of the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders (20/10/2018; Bologna, Italy), the Society of British Neurological Surgeons 2018 Autumn Meeting (19/09/2018; London, United Kingdom), and the European Association of Neurosurgical Societies 2023 congress (27/09/2023; Barcelona, Spain). This work is also part of the doctoral thesis of one of the authors (LD).

PMID: 39905291
PMCID: PMC11792413
DOI: 10.1186/s10194-024-01928-7

AUTHORS: Ian T Mark, Michael Oien, John C Benson, Jared Verdoorn, Ben Johnson-Tesch, D K Kim, Jeremy Cutsforth-Gregory, Ajay A Madhavan

CITATION: AJNR. American journal of neuroradiology, 46(1), 207–210. https://doi.org/10.3174/ajnr.A8437

ABSTRACT: Post-dural puncture headache is an increasingly recognized cause of chronic headache. Outside of clinical history and myelography that requires an additional dural puncture, there is no reliable diagnostic test to evaluate for persistent dural defects. We describe the injection of iodinated contrast into the dorsal epidural space under CT guidance in 5 patients as a potential tool to visualize persistent dural defects.

PMID: 39134368
PMCID: PMC11735425 (available on 2026-01-01)
DOI: 10.3174/ajnr.A8437

AUTHORS: Niklas Lützen, Jürgen Beck, Lalani Carlton Jones, Christian Fung, Theo Demerath, Alexander Rau, Charlotte Zander, Katharina Wolf, Florian Volz, Amir El Rahal, Horst Urbach

CITATION: Radiology, 314(2), e241653. https://doi.org/10.1148/radiol.241653

ABSTRACT: Background Type 2 lateral spinal cerebrospinal fluid (CSF) leakage occurs in approximately 20% of cases of spontaneous intracranial hypotension (SIH); however, the underlying pathologic mechanism remains ambiguous. Purpose To characterize MRI features of type 2 leaks, correlate them with intraoperative observations, and evaluate their diagnostic value. Materials and Methods Patients with SIH and type 2 leaks diagnosed between January 2021 and February 2023 were retrospectively identified. Characteristic imaging features from heavily T2-weighted MR myelography (T2-MRM) images were reevaluated (independently and blinded) in the type 2 leak sample mixed with a sample of 40 patients with SIH and type 1 (ventral) leaks. Available intraoperative data were reviewed for lateral dural tears, arachnoid outpouching, and ruptured spinal meningeal diverticula. Results Twenty-eight patients with SIH (mean age, 37.3 years ± 8.2 [SD]; 22 [79%] female patients) had 29 type 2 leaks between the T7 and L2 levels without side predominance. Characteristic cystic lesions with a broad dural base on the exiting nerve root sleeve were identified at T2-MRM; this “bud-on-branch” sign reflects an arachnoid outpouching herniating through a lateral dural tear, distinct from a meningeal diverticulum, which yielded a sensitivity of 79% (22 of 28; 95% CI: 59, 92) and a specificity of 100% (40 of 40; 95% CI: 91, 100) for leak location. Arachnoid outpouching was confirmed intraoperatively in 23 of 25 patients (92%; 95% CI: 81, 100), originating from the nerve root sleeve axilla in most patients (19 of 25, 76%; 95% CI: 59, 93); two of 25 patients (8%; 95% CI: 0, 19) had a dural tear only, and none had an underlying ruptured meningeal diverticulum. Conclusion This study showed that type 2 leaks are actually due to a lateral dural nerve root sleeve tear through which the arachnoid herniates, which contrasted the common perception that these leaks result from ruptured meningeal diverticula. These leaks had a characteristic anatomic distribution and MRI appearance with substantially facilitated leak localization in patients with SIH. 

PMID: 39932414
DOI: 10.1148/radiol.241653

CITATION: Cephalalgia : an international journal of headache, 45(1), 3331024241308154. https://doi.org/10.1177/03331024241308154

🔓 Open access! Full study available here.

AUTHORS: Dwij Mehta, Sanjay Cheema, Sophie Glover, Ayman M Qureshi, Indran Davagnanam, Salwa Kamourieh, Parag Sayal, Ahmed Toma, Susie Lagrata, Clare Joy, Callum Duncan, Jane Anderson, Brendan Davies, Paul J Dorman, Heather Angus-Leppan, James Walkden, Jonathan Rohrer, Manjit S Matharu

BACKGROUND: Orthostatic headache (OH) is a common feature of various conditions, including spontaneous intracranial hypotension (SIH), but no precise definition currently exists outlining the typical OH characteristics. This ambiguity risks misdiagnosis with unnecessary investigations and delay in institution of treatment. The present study aimed to carry out structured phenotyping of OH in patients with SIH with the aim of outlining its typical characteristics.

METHODS: Eligible patients with clinico-radiological confirmed SIH underwent a structured interview, after which a specialist interest group utilised the modified Delphi process to analyse the data and achieve consensus on defining the typical characteristics of OH in SIH.

RESULTS: In total, 137 patients were recruited. OH was present in 75.9%. Typical OH characteristics in SIH were defined as having a baseline severity (lying flat) on waking up of ≤3 (0-10, verbal response scale), headache onset-time of ≤4.5 h on becoming upright, time to peak severity of ≤7.5 h and an offset to baseline severity within 1.5 h of recumbency. Intra-individual consistency in the onset and offset-time was deemed a necessary characteristic.

CONCLUSIONS: Defining typical OH characteristics has the potential of enhancing SIH diagnostics and management, at the same time as minimising unwarranted invasive procedures.

PMID: 39781568
DOI: 10.1177/03331024241308154

AUTHORS: Peter J Lennarson, Andrew L Callen

CITATION: Neurosurgery clinics of North America, 36(1), 53–64. https://doi.org/10.1016/j.nec.2024.08.003

ABSTRACT: Cerebrospinal fluid (CSF) leaks are a challenging condition characterized by the loss of CSF, leading to severe orthostatic headaches and other debilitating symptoms. Diagnosis and management require a multifaceted approach involving clinical evaluation, imaging, and various treatment modalities to improve patient outcomes and quality of life.

PMID: 39542549
DOI: 10.1016/j.nec.2024.08.003

AUTHORS: Charlotte Zander, Niklas Lützen, Alexander Rau, Katharina Wolf, Philipp Arnold, Hansjörg Mast, Amir El Rahal, Florian Volz, Petra Cimflova, Jürgen Beck, Horst Urbach, Theo Demerath

CITATION: Journal of neurointerventional surgery, jnis-2024-022712. Advance online publication. https://doi.org/10.1136/jnis-2024-022712

BACKGROUND: Cerebrospinal fluid (CSF) loss in spontaneous intracranial hypotension (SIH) is accompanied by volume shifts between the intracranial compartments. This study investigated tricompartimental and longitudinal volume shifts after closure of a CSF leak.

METHODS: Patients with SIH and suitable pre-therapeutic and post-therapeutic imaging for volumetric analysis were identified from our tertiary care center between 2020 and 2023. The Bern SIH score was calculated. Pre-interventional and post-interventional volumetry encompassed the CSF, parenchymal and venous compartments (ie, venous sinus and choroid plexus volumes).

RESULTS: In total, 32 patients with SIH (49.7±16.0 years, 22 women) met inclusion criteria. The mean SIH score decreased between baseline (4.5±2.7) and early (2.7±2.3, <7 days after intervention), and also late follow-up (1.4±1.7, follow-up ≥7 days) after leak closure. This was accompanied by a significant increase in ventricular volume from 22.1 to 25.0 mL (P=0.01) at early follow-up, and 23.9 mL at later follow-up (P=0.080). In contrast, venous sinus volumes decreased from 13.8 to 9.6 mL (P=0.016) at early follow-up, and 10.0 mL (P=0.007) at late follow-up. No significant change in mean choroid plexus, total gray or total white matter volume was observed.

CONCLUSIONS: Closure of a spinal CSF leak leads to an early increase in ventricular CSF volume and a decrease in venous sinus volume. The results reflect the long-term convergence of the SIH score to normal values and indicate that permanent closure of a CSF leak induces a stable recompensation of the intracranial compartments without involving significant volume shifts within the cerebral parenchyma.

PMID: 39870517
DOI: 10.1136/jnis-2024-022712

AUTHORS: Ajay A Madhavan, Vinil Shah, J Levi Chazen, Waleed Brinjikji, Jeremy K Cutsforth-Gregory, Thien Huynh, Ben A Johnson-Tesch, Ian T Mark, Darya P Shlapak, Mark D Mamlouk

CITATION: AJNR. American journal of neuroradiology, 46(2), 421–425. https://doi.org/10.3174/ajnr.A8507 

ABSTRACT: CSF-venous fistulas (CVFs) are a common and increasingly recognized type of spinal CSF leak. Most of these fistulas occur in the setting of spontaneous intracranial hypotension, though nonspontaneous cases have been described as well. In most instances, CVFs arise from the dome or neck of nerve root sleeve diverticula (also called meningeal diverticula). Venous drainage typically involves some combination of the internal epidural venous plexus and external vertebral venous plexus. Not uncommonly, venous drainage into the basivertebral venous plexus or other intraosseous veins can be seen. However, the drainage is usually a secondary finding related to normal communication between intraosseous and extraosseous veins. We have recently observed unique cases in which CVFs arise directly within the vertebral elements, resulting in primarily intraosseous drainage. It is possible that this phenomenon is secondary to prominent meningeal diverticula remodeling the adjacent vertebral elements. In this clinical report, we reviewed a multi-institutional series of CVFs exhibiting primary intraosseous drainage, with the goal of illustrating the imaging findings, treatment strategies, and outcomes of the patients. Nine cases were identified demonstrating this phenomenon. We show that intraosseous CVFs can arise in virtually any part of the vertebrae and describe how this feature affects

PMID: 39884834
DOI: 10.3174/ajnr.A8507

AUTHORS: Lalani Carlton Jones, Diogo G.L. Edelmuth, David Butteriss and Daniel J. Scoffings

CITATION: AJNR. American journal of neuroradiology, 46(1), 211–218. https://doi.org/10.3174/ajnr.A8445

ABSTRACT: Patients with spontaneous intracranial hypotension caused by type 1 dural defects typically have an epidural fluid collection on MRI. Still, the location of the defect is not usually readily identifiable on standard MRI sequences and can be at any point along the length of the collection. The most common location for type 1 leaks is ventral and, as such, these are most commonly associated with ventral predominant epidural fluid. Dynamic myelography (either digital subtraction myelography or dynamic CT myelography) is currently the standard of care for localizing the defect. We describe an imaging sign on T2-weighted images caused by CSF-flow egress at the site of the defect that may permit accurate prediction of the site of the CSF leak noninvasively. Importantly, this sign was only observed on 2D T2-weighted and STIR images and not on 3D acquisitions, which notably suppress artifacts. This has implications for optimal MRI spine protocol construction. This sign can be used to limit myelographic range, reduce radiation dose, and increase diagnostic confidence in dural defect location.

PMID: 39134372
PMCID: PMC11735451 (available on 2026-01-01)
DOI: 10.3174/ajnr.A8445