Abstracts 2024

AUTHORS: Ali Kapan, Thomas Waldhör, Tobias Schiffler, Jürgen Beck, Christian Wöber

CITATION: Journal of Headache and Pain 25, 64 (2024). DOI: 10.1186/s10194-024-01765-8

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BACKGROUND AND OBJECTIVE: Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects.

METHODS: We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21).

RESULTS: A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients’ condition had deteriorated in 32.4% and remained unchanged in 27.9%.

CONCLUSIONS: This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

PMID: 38658862
DOI: 10.1186/s10194-024-01765-8

AUTHORS: Wolf K, Volz F, Lützen N, Mast H, Reisert M, Rahal AE, Fung C, Shah MJ, Beck J, Urbach H.

CITATION: J Neurol (2024). https://doi.org/10.1007/s00415-024-12365-6

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BACKGROUND AND OBJECTIVE: Spontaneous intracranial hypotension (SIH) is an underdiagnosed disease. To depict the accurate diagnosis can be demanding; especially the detection of CSF–venous fistulas poses many challenges. Potential dynamic biomarkers have been identified through non-invasive phase-contrast MRI in a limited subset of SIH patients with evidence of spinal longitudinal extradural collection. This study aimed to explore these biomarkers related to spinal cord motion and CSF velocities in a broader SIH cohort.

METHODS: A retrospective, monocentric pooled-data analysis was conducted of patients suspected to suffer from SIH who underwent phase-contrast MRI for spinal cord and CSF velocity measurements at segment C2/C3 referred to a tertiary center between February 2022 and June 2023. Velocity ranges (mm/s), total displacement (mm), and further derivatives were assessed and compared to data from the database of 70 healthy controls.

RESULTS: In 117 patients, a leak was located (54% ventral leak, 20% lateral leak, 20% CSF–venous fistulas, 6% sacral leaks). SIH patients showed larger spinal cord and CSF velocities than healthy controls: e.g., velocity range 7.6 ± 3 mm/s vs. 5.6 ± 1.4 mm/s, 56 ± 21 mm/s vs. 42 ± 10 mm/s, p < 0.001, respectively. Patients with lateral leaks and CSF–venous fistulas exhibited an exceptionally heightened level of spinal cord motion (e.g., velocity range 8.4 ± 3.3 mm/s; 8.2 ± 3.1 mm/s vs. 5.6 ± 1.4 mm/s, p < 0.001, respectively).

CONCLUSIONS: Phase-contrast MRI might become a valuable tool for SIH diagnosis, especially in patients with CSF–venous fistulas without evidence of spinal extradural fluid collection.

PMID: 38643444
DOI: 10.1007/s00415-024-12365-6

AUTHORS: Wouter I. Schievink, Marcel M. Maya, Angelique Sao-Mai S. Tay, Peyton L. Nisson, Jay Acharya, Rachelle B. Taché and Miriam Nuño

CITATION: American Journal of Neuroradiology, March 2024. DOI: https://doi.org/10.3174/ajnr.A8165

BACKGROUND AND PURPOSE: Spontaneous spinal CSF leaks typically cause orthostatic headache, but their detection may require specialized and invasive spinal imaging. We undertook a study to determine the value of simple optic nerve sheath MR imaging measurements in predicting the likelihood of finding a CSF-venous fistula, a type of leak that cannot be detected with routine spine MR imaging or CT myelography, among patients with orthostatic headache and normal conventional brain and spine imaging findings.

MATERIALS AND METHODS: This cohort study included a consecutive group of patients with orthostatic headache and normal conventional brain and spine imaging findings who underwent digital subtraction myelography under general anesthesia to look for spinal CSF-venous fistulas.

RESULTS: The study group consisted of 93 patients (71 women and 22 men; mean age, 47.5 years; range, 17–84 years). Digital subtraction myelography demonstrated a CSF-venous fistula in 15 patients. The mean age of these 8 women and 7 men was 56 years (range, 23–83 years). The mean optic nerve sheath diameter was 4.0 mm, and the mean perioptic subarachnoid space was 0.5 mm in patients with a CSF-venous fistula compared with 4.9 and 1.2 mm, respectively, in patients without a fistula (P < .001). Optimal cutoff values were found at 4.4 mm for optic nerve sheath diameter and 1.0 mm for the perioptic subarachnoid space. Fistulas were detected in about 50% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements below these cutoff values compared with <2% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements above these cutoff values. Following surgical ligation of the fistula, optic nerve sheath diameter increased from 4.0 to 5.3 mm and the perioptic subarachnoid space increased from 0.5 to 1.2 mm (P < .001).

CONCLUSIONS: Concerns about a spinal CSF leak should not be dismissed in patients with orthostatic headache when conventional imaging findings are normal, and simple optic nerve sheath MR imaging measurements can help decide if more imaging needs to be performed in this patient population.

DOI: https://doi.org/10.3174/ajnr.A8165

AUTHORS: Parikh, S.K.

CITATION: Current Pain and Headache Reports. 2024 Mar 2. doi: 10.1007/s11916-024-01231-9. Online ahead of print.

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PURPOSE OF THIS REVIEW: Rebound intracranial hypertension (RIH) is a post-procedural treatment complication in patients with spontaneous intracranial hypotension (SIH) characterized by transient high-pressure headache symptoms. This article reviews the epidemiology, clinical features, risk factors, and treatment options for RIH.

RECENT FINDINGS: This article discusses how changes in underlying venous pressure and craniospinal elastance can explain symptoms of RIH, idiopathic intracranial hypertension (IIH), and SIH.

SUMMARY: The pathophysiology of RIH provides a clue for how high and low intracranial pressure disorders, such as IIH and SIH, are connected on a shared spectrum.

PMID: 38430310
DOI: 10.1007/s11916-024-01231-9

AUTHORS: Carroll I, Callen AL

CITATION: Headache. 2024; 00: 1-4. Feb 22. doi:10.1111/head.14677

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ARTICLE HIGHLIGHTS:

The last decade has seen a significant improvement in the understanding of spinal cerebrospinal fluid (CSF) leaks and the resulting syndrome of spontaneous intracranial hypotension (SIH). For the reader of Headache and those caring for patients with chronic refractory headaches, three novel concepts are emerging from accumulating data published here and elsewhere: (1) the majority of people with an imaging-proven CSF leak have normal opening pressure; (2) CSF–venous fistulas (CVFs) are a major, rather than rare, cause of SIH; and (3) there is a persistent headache syndrome that occurs at an alarmingly high frequency after unintended dural punctures during epidurals done for analgesia in the obstetric setting.

…In light of these papers, the pre-2019 literature on SIH needs to be critically reappraised. For example, reports that MRI of the spine is 90% sensitive for detecting CSF leaks, largely based on its correlation with non-decubitus CT myelography, should now be understood to mislead more than inform. Such studies evaluated the performance of MRI for detecting CSF leaks by using conventional CT myelography as a gold standard for establishing the presence or absence of epidural fluid collections, but this is an intellectual framework now clearly undermined by CVF, in which no epidural collection is present.

…Another important emerging trend in the field of spinal CSF leaks is the growing understanding that after an unintended dural puncture (such as a dural puncture occurring during a labor epidural), a significant number of patients will report new, or worsened, headaches that persist for years. … These data suggest that for some accidentally punctured patients, the large-bore, cutting tip Tuohy needle intended to facilitate threading of an epidural catheter outside the dura may form a uniquely devastating puncture when advanced unintentionally through the dura.

…In summary, SIH remains a condition that eludes detection, humbles the clinician, and remains the great deceiver, but the headache community is increasingly catching on to its tricks. The incredible advances made in the knowledge of CSF leaks over the past decade are inspiring, and we look forward to the future, where undoubtedly new discoveries await.

PMID: 38385703
DOI: 10.1111/head.14677

AUTHORS: Volz F, El Rahal A, Fung C, Shah M, Lützen N, Urbach H, Beck J, Wolf K

CITATION: Journal of Neurology. 2024 Feb 26. doi: 10.1007/s00415-024-12242-2

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OBJECTIVE: Microsurgical sealing of spinal cerebrospinal fluid (CSF) leaks is a viable treatment option in spontaneous intracranial hypotension (SIH). Several factors may influence the outcome, with symptom duration probably the most modifiable variable.

METHODS: Patients with closure of spinal CSF leaks between September 2020 and March 2023 and a follow-up period of 6 months were included in this retrospective single-center study. Pre- and postoperative scores for impact of headaches (Headache Impact Test, HIT-6) and quality of life (QoL, EQ-5D-5L) were systematically collected. Multiple regression modelling and subgroup analyses for different symptom durations and comorbidities were performed for these outcomes.

RESULTS: One hundred patients (61% female, median age 43.5 years) were included. Six months postoperatively, there was significant improvement in headache impact (HIT-6: 66 (IQR 62-69) to 52 (IQR 40-61, p < 0.001) and QoL (EQ-5D-5L VAS: 40 (IQR 30-60) to 79 (IQR 60-90); EQ-5D-5L Index: 0.67 (IQR 0.35-0.8) to 0.91 (IQR 0.8-0.94, p < 0.001, respectively). Subgroup analysis for a symptom duration above (74%) and below 90 days (26%) and comorbidity, as well as multiple regression analysis, revealed a trend in favor of early treatment and lower comorbidity. However, even after a prolonged symptom duration, improvements were significant.

CONCLUSION: As patients with shorter symptom duration show a trend for a better outcome, our results promote a timely diagnosis and treatment in SIH patients. However, a significant postoperative improvement can still be expected even after a prolonged symptom duration.

PMID: 38409537
DOI: 10.1007/s00415-024-12242-2

AUTHORS: Shahriar Faghani, Mana Moassefi, Ajay A. Madhavan, Ian T. Mark, Jared T. Verdoorn, Bradley J. Erickson, John C. Benson

CITATION: American Journal of Neuroradiology. Feb 2024, DOI: 10.3174/ajnr.A8173

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension is an increasingly recognized condition. Spontaneous intracranial hypotension is caused by a CSF leak, which is commonly related to a CSF-venous fistula. In patients with spontaneous intracranial hypotension, multiple intracranial abnormalities can be observed on brain MR imaging, including dural enhancement, “brain sag,” and pituitary engorgement. This study seeks to create a deep learning model for the accurate diagnosis of CSF-venous fistulas via brain MR imaging.

MATERIALS AND METHODS: A review of patients with clinically suspected spontaneous intracranial hypotension who underwent digital subtraction myelogram imaging preceded by brain MR imaging was performed. The patients were categorized as having a definite CSF-venous fistula, no fistula, or indeterminate findings on a digital subtraction myelogram. The data set was split into 5 folds at the patient level and stratified by label. A 5-fold cross-validation was then used to evaluate the reliability of the model. The predictive value of the model to identify patients with a CSF leak was assessed by using the area under the receiver operating characteristic curve for each validation fold.

RESULTS: There were 129 patients included in this study. The median age was 54 years, and 66 (51.2%) had a CSF-venous fistula. In discriminating between positive and negative cases for CSF-venous fistulas, the classifier demonstrated an average area under the receiver operating characteristic curve of 0.8668 with a standard deviation of 0.0254 across the folds.

CONCLUSIONS: This study developed a deep learning model that can predict the presence of a spinal CSF-venous fistula based on brain MR imaging in patients with suspected spontaneous intracranial hypotension. However, further model refinement and external validation are necessary before clinical adoption. This research highlights the substantial potential of deep learning in diagnosing CSF-venous fistulas by using brain MR imaging.

PMID: 38423747
DOI: 10.3174/ajnr.A8173

AUTHORS: Jeremy D. Schmahmann, MD, and Wouter I. Schievink, MD

CITATION: Neurology Clinical Practice, epub ahead of print (April 2024); https://doi.org/10.1212/CPJ.0000000000200261 

BACKGROUND AND OBJECTIVE: Spontaneous intracranial hypotension (SIH) from CSF leak commonly produces headache. It also may produce sagging brain syndrome (SBS), often with neurocognitive symptoms indistinguishable from behavioral-variant frontotemporal dementia (bvFTD). The authors describe a new clinical sign that appears to be pathognomonic of SBS.

MATERIALS AND METHODS: We reviewed medical records and brain imaging in patients seen at our 2 centers who presented with SIH, SBS, and bvFTD symptoms.

RESULTS: There were 51 patients (12 women, 39 men) with mean age 55.5 years (range, 26–70 years). MRI showed severe brain sagging in all. Thirteen patients displayed repetitive flexion with breath-holding at the time of clinical presentation. Five patients had repetitive flexion with breath-holding, which resolved before presenting for evaluation. Thus, 35.3% (18) of 51 patients with SBS displayed seemingly compulsive repetitive flexion with breath-holding.

DISCUSSION: Compulsive repetitive flexion with breath-holding appears to be pathognomonic of SBS, deserving the acronym CoRFBiS (compulsive repetitive flexion with breath-holding in SBS). CoRFBiS should alert the clinician to SBS with SIH as the proximate cause of the clinical constellation, rather than bvFTD.

DOI: 10.1212/CPJ.0000000000200261 

AUTHORS: Andrew L. Callen, Mo Fakhri, Vincent M. Timpone, Ashesh A. Thaker, William P. Dillon and Vinil N. Shah

CITATION: American Journal of Neuroradiology, January 2024, 45 (1) 100-104; DOI: 10.3174/ajnr.A8078 

BACKGROUND AND PURPOSE: CSF-venous fistula can be diagnosed with dynamic decubitus CT myelography. This study aimed to analyze the temporal characteristics of CSF-venous fistula visualization on multiphase decubitus CT myelography.

MATERIALS AND METHODS: A retrospective, multisite study was conducted on patients diagnosed with CSF-venous fistula at 2 institutions between June 2017 and February 2023. Both institutions perform decubitus CT myelography with imaging immediately following injection and usually with at least 1 delayed scan. The conspicuity of CSF-venous fistula was assessed on each phase of imaging.

RESULTS: Forty-eight patients with CSF-venous fistula were analyzed. CSF-venous fistulas were better visualized on the early pass in 25/48 cases (52.1%), the delayed pass in 6/48 cases (12.5%) and were seen equally on both passes in 15/48 cases (31.3%). Of 25 cases in which the CSF-venous fistula was better visualized on the early pass, 21/25 (84%) fistulas were still at least partially visible on a delayed pass. Of 6 cases in which the CSF-venous fistula was better visualized on a delayed pass, 4/6 (67%) were partially visible on the earlier pass. Six of 48 (12.5%) CSF-venous fistulas were visible only on a single pass. Of these, 4/6 (66.7%) were seen only on the first pass, and 2/6 (33.3%) were seen only on a delayed pass. One fistula was found with one pass only, and one fistula was discovered upon contralateral decubitus imaging without a dedicated second injection.

CONCLUSIONS: A dynamic decubitus CT myelography imaging protocol that includes an early and delayed phase, likely increases the sensitivity for CSF-venous fistula detection. Further studies are needed to ascertain the optimal timing and technique for CSF-venous fistula visualization on dynamic decubitus CT myelography and its impact on patient outcomes.

PMID: 38123910
DOI: 10.3174/ajnr.A8078

AUTHORS: Fides R. Schwartz, MD, Peter G. Kranz, MD, Michael D. Malinzak, MD, David N. Cox, PhD, Francesco Ria, PhD, Cindy McCabe, MA, Brian Harrawood, MA, Linda G. Leithe, MD, Ehsan Samei, PhD, and Timothy J. Amrhein, MD

CITATION: American Journal of Roentgenology January 31 2024, https://doi.org/10.2214/AJR.23.30673

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BACKGROUND: CSF-venous fistulas (CVFs) are an increasingly recognized cause of spontaneous intracranial hypotension (SIH) that are often diminutive in size and exceedingly difficult to detect by conventional imaging.

OBJECTIVE: This study’s objective was to compare EID-CT myelography and PCD-CT myelography in terms of image quality and diagnostic performance for detecting CVFs in patients with SIH.

METHODS: This retrospective study included 38 patients (15 men, 23 women; mean age, 55±10 years) with SIH who underwent both clinically indicated EID-CT myelography (slice thickness, 0.625 mm) and PCD-CT myelography (slice thickness, 0.2 mm; performed in ultrahigh-resolution mode) to assess for CSF leak. Three blinded radiologists reviewed examinations in random order, assessing image noise, discernibility of spinal nerve root sleeves, and overall image quality using 0-100 scales (100=highest quality), and recording locations of CVFs. Definite CVFs were defined as CVFs described in CT myelography reports using unequivocal language and showing attenuation >70 HU.

RESULTS: For all readers, PCD-CT myelography, in comparison with EID-CT myelography, showed higher image noise (reader 1: 69±19 vs 38±15; reader 2: 59±9 vs 49±13; reader 3: 57±13 vs 43±15), higher nerve root sleeve discernibility (reader 1: 84±19 vs 30±14; reader 2: 84±19 vs 70±19; reader 3: 60±13 vs 52±12), and higher overall image quality (reader 1: 84±21 vs 40±15; reader 2: 81±10 vs 72±20; reader 3: 58±11 vs 53±11) (all p<.05). Eleven patients had a definite CVF. Sensitivity and specificity for detection of definite CVF for EID-CT myelography and PCD-CT myelography for reader 1 were 45% and 96% versus 64% and 85; for reader 2 were 36% and 100% versus 55% and 96%; and for reader 3 were 45% and 100% versus 55% and 93%. For all readers, PCD-CT myelography, in comparison with EID-CT myelography, showed significantly higher sensitivity (all p<.05), without significant difference in specificity (all p>.05).

CONCLUSION: In comparison with EID-CT myelography, PCD-CT myelography yielded significantly improved image quality with significantly higher sensitivity for CVFs without significant loss of specificity.

CLINICAL IMPACT: The findings support a potential role of PCD-CT myelography in facilitating earlier diagnosis and targeted treatment of SIH, avoiding high morbidity during potentially prolonged diagnostic workups.

PMID: 38294163
DOI: 10.2214/AJR.23.30673

AUTHORS: Thien J. Huynh, Donna Parizadeh, Ahmed K. Ahmed, Christopher T. Gandia, Hal C. Davison, John V. Murray, Ian T. Mark, Ajay A. Madhavan, Darya Shlapak, Todd D. Rozen, Waleed Brinjikji, Prasanna Vibhute, Vivek Gupta, Kacie Brewer and Olga Fermo

CITATION: American Journal of Neuroradiology January 2024, 45 (1) 105-112; DOI: https://doi.org/10.3174/ajnr.A8082

BACKGROUND AND PURPOSE: CSF-venous fistulas (CVFs) associated with spontaneous intracranial hypotension (SIH) may have a transient appearance, relative to contrast arrival, which may influence the diagnostic performance of lateral decubitus CT myelography (CTM). We developed a dynamic CTM protocol using real-time bolus-tracking (dCTM-BT) to improve the temporal resolution and standardize the timing of CTM acquisitions post-intrathecal contrast administration. The purpose of our study was to evaluate the feasibility of the dCTM-BT technique and evaluate its diagnostic yield for CVF detection, stratified by brain MRI SIH findings.

MATERIALS AND METHODS: Patients with suspected SIH without extradural fluid collection on spine MRI who underwent dCTM-BT were retrospectively reviewed. CT bolus monitoring was performed at the upper thoracic level. Following the visualization of dense intrathecal contrast, at least 3 CTM acquisitions of the spine were obtained and reviewed by 2 neuroradiologists. The Bern SIH score was calculated on the brain MRI. The diagnostic yield for CVF detection was evaluated, stratified by Bern score categories and a receiver operating characteristic (ROC) analysis.

RESULTS: Out of 48 patients, 23 (48%) had a CVF on dCTM-BT, located at T1–5 (n = 4), T6–12 (n = 18), L1 (n = 1), with 70% on the right. CVF was identified in 22/22 (100%) of patients who had a high Bern score, 1/7 (14%) of those who had an intermediate score, and 0/19 (0%) of those who had a low score. The area under the ROC curve was 0.99 (95% CI, 0.98–1.00). The optimal cutoff was a Bern score of ≥5 (96% sensitivity, 100% specificity).

CONCLUSIONS: dCTM-BT is feasible and has excellent diagnostic performance for CVF identification/localization. The Bern score is strongly associated with CVF detection and may help inform who will benefit from dCTM-BT.

PMID: 38164531
DOI: 10.3174/ajnr.A8082

AUTHORS: Zayat R, Huynh TJ, Fermo O

CITATION: Journal of Neuro Interventional Surgery, doi: 10.1136/jnis-2023-021053

BACKGROUND: The majority of patients with spontaneous intracranial hypotension (SIH) are symptomatic. Some patients are discovered incidentally. The proportion of asymptomatic SIH has never been defined. This article reports our institution’s rate of asymptomatic cases among all of our patients with high/intermediate Bern scores on brain MRI, etiology of leak in asymptomatic cases, complications of asymptomatic leaks, and evolution of imaging before and after treatment.

METHODS: We retrospectively analyzed data from the Cerebrospinal Fluid (CSF) Dynamics clinic spanning September 2020 to July 2023. Bern score was calculated from all available brain MRIs in patients with confirmed leaks. Patients with iatrogenic leaks or no brain MRI were excluded. The charts of asymptomatic patients were reviewed to obtain MRI indications, SIH progression, complications, leak type, and treatment outcomes.

RESULTS: Some 8.6% (7/81) patients with high/intermediate Bern scores were asymptomatic at the time of imaging. Two patients declined myelography. Four of seven asymptomatic patients were found to have CSF-venous fistulas and underwent embolization with radiographic improvement. Complications of asymptomatic leaks in this population included subdural hematoma and superficial siderosis.

CONCLUSIONS: Asymptomatic but clearly present spinal CSF leaks were not uncommon in our group. These results highlight the possibility of a presymptomatic phase in patients with CSF leaks. In our sample, myelography was readily positive for etiology of the leak, and leaks promptly responded to targeted treatment.

doi: 10.1136/jnis-2023-021053

AUTHORS: Zayat R, Fermo OP, Huynh TJ.

CITATION: Neurol Neurochir Pol. 2024 Jan 31. doi: 10.5603/pjnns.97522. Epub ahead of print.

AIM OF THE STUDY: This study presents cases of recurrent cerebrospinal fluid-venous fistulas (CVFs) de novo at a different spinal level following successful treatment of initial CVFs. The aim was to highlight this rarely described phenomenon and report the clinical and imaging features after initial treatment, providing insights into the dynamics of recurrent CVFs.

CLINICAL RATIONALE FOR THE STUDY: Understanding the course of CVFs post-treatment is crucial for optimising patient management, especially when symptoms persist or recur.

MATERIAL AND METHODS: We performed a retrospective chart review of all patients with recurrent CVFs at a different level after treatment of their initial CVF at our institution. Clinical and imaging records were reviewed and summarised, including Bern score features on brain magnetic resonance imaging (MRI) before and after treatment.

RESULTS: Four patients with five recurrent CVFs were identified. Recurrent or persistent symptoms encouraged subsequent brain MRI scans, which revealed different outcomes: i.e. persistence, or improvement, or complete resolution of abnormal findings. Initial positive responses included improvement of the pachymeningeal enhancement and venous sinus distension. These improvements were reversed when recurrent symptoms arose, which was also correlated with changes in the Bern score.

CONCLUSIONS AND CLINICAL IMPLICATIONS: Recognizing the factors of CVF recurrence is crucial for comprehensive management. This study underlines the significance of repeated evaluation of persistent or recurring symptoms of CSF leak after treatment for CVFs.

PMID: 38294430
DOI: 10.5603/pjnns.97522