Publication abstracts about spinal CSF leak from 2026

AUTHORS: James Evans, Julia Lowin, Pippa Anderson 

CITATION: Cost effectiveness and resource allocation : C/E, 10.1186/s12962-025-00612-0. 6 Mar. 2026, doi:10.1186/s12962-025-00612-0

🔓Open access! Full study available here. 

INTRODUCTION: Clinical evidence indicates that atraumatic needles (ATNs) versus conventional needles (CNs) reduce diagnostic lumbar puncture (DLP) complications. Despite this, the use of CNs in DLP remains widespread. This analysis estimates the cost-effectiveness of ATNs versus CNs in DLP.

METHODS: We constructed a model mapping DLP patient pathways and complications (limited to PDPH events and PDPH-related hospitalisations/epidural blood patches (EBP)). Model development was carried out in consultation with local clinical experts. Published data informed clinical data inputs (DLP characteristics and likelihood of PDPH) and resource estimates. Costs of PDPH management were estimated from UK NHS Reference Costs. Costs of LP were limited to needle costs. Model outputs included total PDPH, total costs, cost per PDPH avoided and numbers need to treat (NNT) to avoid one case of PDPH. Extensive one-way sensitivity analyses were conducted.

RESULTS: Based on 100 patients undergoing DLP with CN (ATN), we estimated 31 (12) cases of PDPH with 7 (3) patients requiring EBP with total costs estimated at £9,469 (£4,257) i.e. 19 fewer cases of PDPH with ATN at a cost saving of £5,212. NNT to avoid one case of PDPH (hospitalised PDPH) was estimated at 5 (13). Clinical benefits and cost savings were robust to plausible input changes.

DISCUSSION AND CONCLUSION: Our model findings support an economic case for use of ATN in preference to CN in DLP, with improved outcomes achieved at a cost saving. Local data collection is recommended but is not expected to change the model findings.

PMID: 41792808
DOI: 10.1186/s12962-025-00612-0

AUTHORS: Charlotte Zander, Alexander Rau, Niklas Lützen, Katharina Wolf, Florian Volz, Amir El Rahal, Laura Krismer, Hansjörg Mast, Marco Reisert, Elias Kellner, Jürgen Beck, Horst Urbach, Theo Demerath 

CITATION :Fluids and barriers of the CNS, 10.1186/s12987-026-00785-7. 3 Mar. 2026, doi:10.1186/s12987-026-00785-7

🔓Open access! Full study available here. 

BACKGROUND: CSF loss in spontaneous intracranial hypotension (SIH) has been related to alterations in glymphatic flow, which is poorly understood in this disease. Advanced multi-shell diffusion-weighted MRI (dMRI) enables quantification of the interstitial free water fraction, serving as a possible surrogate marker for glymphatic system function in patients with SIH.

METHODS: SIH Patients underwent dMRI before and after closure of a spinal CSF leak. The microstructural free water compartment (V-CSF) of the whole brain gray and white matter, corona radiata, amygdala, hippocampi and parahippocampal gyri was compared to 23 age-matched normal controls. Pre- and post-therapeutic volumetry encompassed the total ventricular, total gray and white matter compartments and mesial temporal structures.

RESULTS: 23 SIH patients (50.3 ± 13.1 years, 15 women) were included. After leak closure, V-CSF increased in the global gray matter (mean pre 0.140 vs. mean post 0.151; p = 0.029), posterior corona radiata (mean pre 0.103 vs. mean post 0.108; p = 0.0055), hippocampi (mean pre 0.100 vs. mean post 0.105; p = 0.001), and parahippocampal gyri (mean pre 0.156 vs. mean post 0.177; p = 0.009). Compared to normal controls, V-CSF was decreased before leak closure in the hippocampi (mean pre 0.100 vs. mean NC 0.211; p = 0.0019) and posterior corona radiata (mean pre 0.103 vs. mean NC 0.118; p = 0.011). No significant change of total gray or white matter volume occurred after leak closure.

CONCLUSION: Closure of the spinal CSF leak leads to an increase of interstitial fluid in gray matter, corona radiata, hippocampi, and parahippocampal gyri, respectively. Our results suggest, that SIH patients may have less interstitial fluid in the hippocampi and posterior corona radiata compared to normal controls. Whether shifts in brain interstitial fluid in eloquent cerebral regions contribute to cognitive decline in patients with CSF loss should be topic of further research.

PMID: 41776643
DOI: 10.1186/s12987-026-00785-7

AUTHORS: Zaid Saadeh, Sherief A Ghozy, Esref A Bayraktar, Waleed Brinjikji, Ajay A Madhavan, John C Benson, Jared T Verdoorn, Parnian Habibi, Jeremy K Cutsforth-Gregory, Ian T Mark 

CITATION: AJNR. American journal of neuroradiology, ajnr.A9187. 2 Mar. 2026, doi:10.3174/ajnr.A9187

BACKGROUND AND PURPOSE: CSF-venous fistulas (CVFs) are an important and underrecognized cause of spontaneous intracranial hypotension. They are direct communications between the subarachnoid space and paraspinal vein resulting in loss of CSF. We performed a systematic review and meta-analysis to evaluate the prevalence of affected laterality or spinal levels.

METHODS AND MATERIALS: A literature review identified 587 studies for possible inclusion and 43 were selected as relevant by two screeners. Studies from the same institution with data overlap and <3 subjects were removed. Demographic characteristics, side of involvement and spinal levels of CVFs were collected when available and included in the analysis. Pooled prevalence rates were computed, and age and gender distribution across studies were analyzed. Pairwise meta-regression was used, and laterality was further assessed at each spinal level to determine the distribution of right- versus left-sided leaks. Statistical significance was defined as p < 0.05.

RESULTS: CVFs were most common on the right compared to other patterns such as left-sidedness and bilaterally (67% CI: 0.62-0.73; p <0.001). Nearly all were in the thoracic spine (96% CI: 0.93-0.98). T7 and T9 demonstrated the highest prevalence rate for specific spinal levels out of the analyzed CVFs at 19% each. T10 also showed high prevalence rate of 17%. The lumbar and cervical spine demonstrated significantly lower prevalence when compared to the thoracic region (P<0.001). Descriptive analysis of the CVFs by spinal level and laterality demonstrated that the major leak sites were right T7 (7.8%), T6 (6%), and T10 (5.5%).

CONCLUSIONS: Localization of CVFs is crucial in therapeutic planning and intervention. We found significantly more on the right utilizing the available literature for analysis. The greatest prevalence rates by level were in the lower thoracic spine at T7, T9, and T10. One possible etiology for this pattern could be the azygous vein and an abundance of arachnoid granulations at these levels.

PMID: 41771733
DOI: 10.3174/ajnr.A9187

AUTHORS: Eike I Piechowiak, Fabio Pisi, Thomas Petutschnigg, Jan Gralla, Johannes Kaesmacher, Ralph T Schär, Andreas Raabe, Levin Häni, Johannes Goldberg, Jean-Benoît Rossel, Katharina Wolf, Jürgen Beck, C Marvin Jesse, Tomas Dobrocky

CITATION: AJNR. American journal of neuroradiology, 10.3174/ajnr.A9055. 26 Feb. 2026, doi:10.3174/ajnr.A9055

🔓Open access! Full study available here. 

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension (SIH) is caused by CSF leakage at the spinal level, resulting in craniospinal CSF depletion and often debilitating symptoms. While changes in intracranial CSF volume in SIH, particularly early depletion and normalization after treatment, are documented, reports of spinal CSF volumetry remain scarce. This study aimed to quantify intrathecal spinal CSF volume in patients with SIH before and after definitive leak closure and compare it with that in a non-SIH control cohort.

MATERIALS AND METHODS: This retrospective, single-center study included 35 patients with SIH with confirmed spinal CSF leaks (types 1-3) and 10 non-SIH controls. All patients with SIH underwent surgical or endovascular leak closure and had high-quality pre- and posttreatment isotropic 3D T2-weighted MR imaging. Spinal intrathecal CSF volume was measured using semi-automated segmentation, excluding spinal longitudinal epidural fluid collections (SLEC), if present. Paired and unpaired statistical tests were applied.

RESULTS: In total 18, SLEC-positive (+) and 17 SLEC-negative (-) patients and 10 non-SIH controls were evaluated. After successful leak closure, spinal CSF volume increased significantly in patients with SIH (+13%, P < .001). This increase was seen in both SLEC+ (+18%, P < .001) and SLEC- (+5%, P = .02) subgroups. No significant difference was observed between patients with SIH pretreatment and controls. However, posttreatment volumes in patients with SIH were significantly higher than those in controls (+13%, P = .04).

CONCLUSIONS: Spinal CSF volumetry reliably detects a significant increase in intrathecal CSF volume following definitive leak closure in patients with SIH. Notably, posttreatment spinal CSF volumes exceeded those of non-SIH controls, suggesting a potential compensatory mechanism with overshooting CSF volume after prolonged CSF depletion.

PMID: 41748435
DOI: 10.3174/ajnr.A9055

AUTHORS: Wouter I Schievink, Marcel M Maya, Rachelle B Taché, Ravi S Prasad, Vikram Wadhwa, Franklin G Moser

CITATION: AJNR. American journal of neuroradiology, ajnr.A9258. 23 Feb. 2026, doi:10.3174/ajnr.A9258

BACKGROUND AND PURPOSE: Spinal CSF-venous fistulas are an important cause of spontaneous intracranial hypotension (SIH). Most of these fistulas are associated with a meningeal diverticulum, but they arise from the largest diverticulum in only about one-third of cases. De novo recurrent CSF-venous fistulas are defined as a CSF-venous fistula at a different spinal level (or side) following treatment of the initial CSF-venous fistula. Such de novo recurrent fistulas offer a unique opportunity to study the growth of diverticula prior to the development of a fistula.

METHODS: In this single-center retrospective observational study, data elements indicating a de novo recurrent fistula were extracted from a prospectively maintained data base. Using this registry, we identified a consecutive group of patients with de novo recurrent fistulas.

RESULTS: The study population consisted of nine women and six men (mean age: 57.9 years) with SIH and a de novo recurrent fistula. All patients had multiple diverticula, ranging from three to 35 diverticula per patient (total: 215 diverticula). The initial fistula was treated with microsurgical clip ligation in all patients. The mean interval between initial fistula treatment and de novo recurrent fistula formation was two years and four months (range, five months to six years and six months). A change in diverticular size (mean, 2 mm; range: 1 to 3 mm) associated with the de novo recurrent fistula was observed in five (33.3%) of the 15 patients. Diverticular size had increased in three patients and decreased in two patients. No change in size was observed in the other 195 meningeal diverticula.

CONCLUSIONS: We found that in one-third of patients a change in diverticular size was observed corresponding to the site of the de novo recurrent fistula. An increase in diverticular size could be explained by increased diverticular wall tension (law of LaPlace) and attenuation of the diverticular wall resulting in a higher likelihood of developing a CSF-venous fistula and a decrease in size could be explained by decompression of the diverticulum through the fistula. A change in size of meningeal diverticula may help guide the invasive myelographic studies necessary to locate CSF-venous fistulas.

PMID: 41730631
DOI: 10.3174/ajnr.A9258

AUTHORS: Fatma Merzou, Anna-Lena Kunzmann, Daniel Janitschke, Jose Valdueza, Benjamin Landau, Sebastian Roemer, Erwin Stolz, Laurin Schappe, Viviana Versace, Steffen Kottackal, Piergiorgio Lochner

CITATION: Scientific reports, 10.1038/s41598-026-40311-1. 20 Feb. 2026, doi:10.1038/s41598-026-40311-1

🔓Open access! Full study available here. 

ABSTRACT: The aim of our study is to test the hypothesis whether ultrasonographically measured ultrasound-guided optic nerve sheath diameter (US-ONSD) decreases after lumbar puncture (LP) and whether decreased optic nerve sheath diameter (ONSD) after lumbar puncture is associated with headache. The latter might help to identify patients with postdural puncture headache (PDPH). In this prospective observational study 76 patients, who had undergone diagnostic LP using an atraumatic technique, received a measurement of ONSD before (T0), immediately after (T1) and 24 h after LP (T2). Additionally demographic data such as age, sex, body mass index (BMI), and also headaches and symptoms were recorded. In six out of 7 patients with constant PDPH, we additionally measured ONSD 48 h (T3) and 72 h (T4) after LP. All patients (n = 76, 100%) showed a physiological reduction in ONSD at T1. Patients with consistent symptoms of PDPH (n = 7, 9%) kept values below pre-LP levels after 24 and 48 h. No statistical difference was found in BMI, sex, cerebrospinal fluid volume, needle size, or previous headaches between the PDPH (n = 7, 9%) and non-PDPH patients (n = 69, 91%). Younger patients were more likely to experience PDPH symptoms. Since at T2 the ONSD was only reduced in PDPH patients, a significant difference in ONSD was found between PDPH and non-PDPH patients. The cut-off value of ONSD for predicting PDPH at T2 was 4.9 mm in the receiver operating characteristic (ROC) curve (sensitivity 86%, specificity 93%). We were able to demonstrate a physiologic change in ONSD after LP in all patients. The sonographic measurement of ONSD in patients with headache can help to identify and monitor PDPH after LP.

PMID: 41720848
DOI: 10.1038/s41598-026-40311-1

AUTHORS: Eric Esposito, Shenghua Zhu, Edwin Owolo, Gabriel N Friedman, Elie Massaad, Kathleen M Lavoie, Theresa Williamson, Jean Valery Coumans, Lawrence F Borges, Neel Madan, Bart K Chwalisz, Aaron Paul, Ganesh M Shankar

CITATION:Journal of neurosurgery. Case lessonsvol. 11,7 CASE25819. 16 Feb. 2026, doi:10.3171/CASE25819

🔓Open access! Full study available here. 

BACKGROUND: Spontaneous intracranial hypotension (SIH) may result in positional headaches, tinnitus, vestibular symptoms, and cognitive dysfunction. Pachymeningeal enhancement may be seen on contrast-enhancing imaging. Notably, the time course of pachymeningeal enhancement resolution has previously been shown to resolve within 17 hours of surgical repair. The authors sought to determine whether radiographic stigmata of SIH could be used as a marker for effective treatment.

OBSERVATIONS: A retrospective review of 14 patients who underwent open surgical management for SIH was conducted. Clinical notes and pre-and postoperative images were used to determine resolution of pachymeningeal enhancement. All patients experienced resolution of preoperative positional headaches on initial follow-up, with a median of 12 days following surgery. Diffuse pachymeningeal enhancement was found on preoperative MRI brain in all patients, with postoperative imaging showing resolution of pachymeningeal enhancement, with a median of 2 days postsurgery.

LESSONS: Diffuse pachymeningeal enhancement is a reliable marker for resolution SIH and often predates clinical resolution. Therefore, the authors propose that assessing for this characteristic with contrasted-brain MRI may assist in the posttreatment evaluation of patients with SIH.

PMID: 41698188
PMCID: PMC12908245
DOI: 10.3171/CASE25819

AUTHORS: Ajay A Madhavan, Michelle L Kodet, Marcel M Maya, Wouter I Schievink, Thien Huynh 

CITATION: AJNR. American journal of neuroradiology, 10.3174/ajnr.A9058. 12 Feb. 2026, doi:10.3174/ajnr.A9058

ABSTRACT: CSF-venous fistulas are a common cause of spontaneous intracranial hypotension. Most CSF-venous fistulas occur in the thoracic spine, and recently described myelographic techniques have been primarily tailored to localize fistulas in this location. However, a small subset of CSF-venous fistulas can occur at the superior or inferior ends of the spine, ranging from the skull base to the sacrum. In this Video Article, we discuss modifications to decubitus myelography needed to safely and confidently diagnose CSF-venous fistulas at the extremes of the spine, including the skull base and sacrum. We also show unique case examples of these relatively uncommon leaks, which were found using decubitus digital subtraction or CT myelography with simple technical modifications.

PMID: 41679905
DOI: 10.3174/ajnr.A9058

AUTHORS: Parnian Habibi, Andrew Callen, Jared Verdoorn, John Benson, Ajay A Madhavan, Sara Salehi, Jeremy Cutsforth-Gregory, Ian T Mark

CITATION: AJNR. American journal of neuroradiology, ajnr.A9209. 7 Feb. 2026, doi:10.3174/ajnr.A9209

ABSTRACT: Spontaneous intracranial hypotension (SIH) is a debilitating and often misdiagnosed condition. One important differential diagnosis is Chiari malformation type 1 (CM-1), which differs markedly in its pathophysiology, clinical manifestation, and treatment. We report seven cases of SIH initially misdiagnosed as CM-1, emphasizing the importance of considering SIH when evaluating low-lying cerebellar tonsils to prevent unnecessary procedures and delays in appropriate treatment.

PMID: 41654330 
DOI: 10.3174/ajnr.A9209

AUTHORS: Alexandre Bani-Sadr, Apolline Guérin, Caroline Froment Tilikete, Geneviève Demarquay, Virginie Desestret, Yves Berthezène, Mark D Mamlouk 

CITATION: AJNR. American journal of neuroradiology, ajnr.A9216. 7 Feb. 2026, doi:10.3174/ajnr.A9216

ABSTRACT: We evaluated the safety and efficacy of CT-guided intracystic fibrin glue injection for cerebrospinal fluid-venous fistulas (CVFs) causing spontaneous intracranial hypotension. In this 2-center retrospective series, 16 patients underwent fibrin injection directly into the diverticular cyst, with additional epidural or paravertebral injection as needed. Median intracystic fibrin volume was 1.0 mL; thecal sac extension was present in 44% of cases. No serious or permanent complications, arachnoiditis, or neurologic deficits were observed. Transient rebound intracranial hypertension occurred in 31% and transient radicular pain in 6%, both resolving spontaneously. Clinical outcomes were favorable, with 88% of patients reporting complete and 12% partial symptom improvement. The median Bern score decreased from 6.0 pretreatment to 0 posttreatment, and CT myelography in a subset confirmed fistula closure. CT-guided intracystic fibrin glue injection appears to be a safe, effective, and targeted option for CVF treatment, meriting further prospective evaluation.  

PMID: 41654329
DOI: 10.3174/ajnr.A9216

AUTHORS: Kaissar Sassi, Rachel Fresquet, Marie-Lucie Dubois, Vincent Minville, Thomas Geeraerts 

CITATION: Journal of clinical monitoring and computing, 10.1007/s10877-025-01395-8. 5 Feb. 2026, doi:10.1007/s10877-025-01395-8

🔓Open access! Full study available here. 

ABSTRACT: Post-dural puncture headache (PDPH) following epidural anesthesia remains a frequent obstetric complication. While epidural blood patch (EBP) is the reference treatment, its efficacy assessment still relies on subjective pain reporting. This study explored whether changes in optic nerve sheath diameter (ONSD) measured by ultrasound could serve as an objective, real-time indicator of early EBP response. In this prospective, single-center observational study, 30 postpartum patients with PDPH undergoing EBP had ONSD measured before (H0) and 2 h after (H2) the procedure. Correlation between ΔONSD and ΔVAS pain scores was analyzed with bootstrap validation, and receiver operating characteristic (ROC) analysis identified thresholds associated with early response. Mean ΔONSD was 0.97 ± 0.55 mm, significantly correlated with pain reduction (r = – 0.64, p < 0.001; bootstrap 95% CI: -0.81 to – 0.36). ROC analysis showed good diagnostic performance (AUC = 0.96, 95% CI: 0.87-1.00), with a ΔONSD ≥ 0.40 mm threshold providing 100% sensitivity and 83% specificity for early improvement. These preliminary findings suggest that ONSD ultrasound may offer a feasible, noninvasive adjunct for assessing early EBP response in PDPH. The identified 0.40 mm change threshold appears promising but requires confirmation in larger, multicenter studies with extended follow-up to determine its reproducibility and clinical utility.

PMID: 41642543  
DOI: 10.1007/s10877-025-01395-8

AUTHORS: Mazin Omer, Katharina Wolf, Manou Overstijns, Amir El Rahal, Niklas Lützen, Horst Urbach, Charlotte Zander, Laura Krismer, Jan-Helge Klingler, Marc Hohenhaus, Mukesch Shah, Jürgen Beck, Florian Volz

CITATION: Frontiers in Neurology vol. 17 (2026): 1738826. doi:10.3389/fneur.2026.1738826

🔓Open access! Full study available here. 

INTRODUCTION: Spontaneous intracranial hypotension (SIH) due to a spinal cerebrospinal fluid (CSF) leak is a debilitating but curable condition, often affecting individuals of working age, making a considerably socioeconomic impact likely.

METHODS: This monocentric retrospective study in Germany analyzed work capacity in patients ≤65 years before and after surgical closure of a spinal CSF leak between April 2018 and September 2024. The economic burden was evaluated via direct hospital costs and indirect costs from productivity losses.

RESULTS: Two hundred and ten patients (median age 45.5 years, 62% female), all physically capable of working, were included. After symptom onset, 96% could not perform their professional work as before: 61% were completely unable, 18% reduced working time, and 17% adapted conditions. Three months postoperatively, 55% had completely returned to work, 19% were working part-time. At the last follow-up these numbers further improved to 65 and 17%, respectively, only 9% were still unable to work, 9% had retired. A shorter symptom duration was significantly associated with complete return to work. Median direct costs per patient for diagnosis and treatment was €11,407, indirect costs for 160 days (the median symptom duration before surgery) averaged €21,169. Extrapolated to the incidence rate, the additional annual economic burden in Germany is estimated at €85.75 million for 160 sick days, largely from preventable productivity losses.

CONCLUSION: SIH significantly impairs working ability. Early treatment can restore work capacity and substantially reduces preventable productivity losses, strongly advocating timely intervention not only from a medical but also from an economic perspective.

PMID: 41695621
PMCID: PMC12894015
DOI: 10.3389/fneur.2026.1738826

AUTHORS: Victor Liaw, Deborah I Friedman 

CITATION: Neurology. Clinical practice vol. 16,2 (2026): e200585. doi:10.1212/CPJ.0000000000200585

BACKGROUND AND OBJECTIVES: Spontaneous intracranial hypotension (SIH) profoundly affects quality of life. We aimed to identify and quantify various aspects of patients’ experiences with SIH.

METHODS: We piloted an “SIH Impact Inventory,” a cross-sectional survey developed in collaboration with patients, family members, and caregivers. Potential participants were identified from a single center using diagnosis and procedure codes. Participants completed the inventory online using REDCap between December 2021 and April 2022.

RESULTS: Ninety-eight adult patients completed the inventory. The mean age was 50.6 years, and 69.4% were female. Sixty-three percent had a confirmed diagnosis of SIH, and 36.7% had clinically suspected but unconfirmed SIH. The mean time to diagnosis was 2.0 (interquartile range: 0.5-4.8) years; 25.5% went undiagnosed for 5 or more years, and 75% were initially misdiagnosed. The 3 most common symptoms were head pain, neck pain, and “brain fog.” Of those undergoing epidural blood patch procedures, 22% experienced relief of symptoms for a median time of 1.3 months; those with a confirmed diagnosis had more prolonged relief. 58.2% reported experiencing rebound intracranial hypertension after a therapeutic procedure. Surgical repair of the leak was most likely to result in a symptom-free status (p = 0.003) than nonsurgical treatments. Of those working for compensation when they developed SIH, 95.2% indicated that the condition affected their ability to work and 65.1% stopped working. The financial burden was substantial for 65.3% of our cohort, with medical expenses (98.4%) and travel for health care (65.6%) being the most prevalent expenses. SIH negatively affected personal and family relationships for most patients.

DISCUSSION: Individuals with confirmed and suspected SIH experience difficulties related to the disorder itself and the lengthy process of diagnosis and treatment. Our findings demonstrate the marked impact of SIH on employment, education, interpersonal relationships, and finances. Compared with previous studies, our cohort reported considerable cognitive difficulties, with rates approaching those of head pain. Heightened awareness of SIH, referral to a center with expertise in SIH, increasing the number and geographic distribution of SIH centers, and advances in diagnostic and treatment modalities can help alleviate some of the challenges that patients face.

PMID: 41626517
PMCID: PMC12854680 (available on 2027-04-01)
DOI: 10.1212/CPJ.0000000000200585

AUTHORS: Federico Cagnazzo, Andrés Ortiz Giraldo, Nicolas Lonjon, Vincent Costalat, Anne Ducros 

CITATION: Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, 15910199261416268. 27 Jan. 2026, doi:10.1177/15910199261416268

ABSTRACT: Cerebrospinal fluid-venous fistula (CSFVF) is an increasingly recognized cause of spontaneous intracranial hypotension (SIH). We present a rare case of a 41-year-old woman with SIH caused by a right S2-S3 CSFVF draining in the right internal iliac vein. Successfully transvenous endovascular embolization using Onyx was performed. This report highlights diagnostic challenges and procedural details, emphasizing the efficacy of endovascular approaches in managing CSFVF in atypical anatomical locations.

PMID: 41591940  
PMCID: PMC12846900
DOI: 10.1177/15910199261416268

AUTHORS: Wouter I Schievink, Marcel M Maya, Andre E Boyke, Franklin G Moser, Ravi S Prasad, Vikram Wadhwa, Xuemo Fan 

CITATION: AJNR. American journal of neuroradiology, 10.3174/ajnr.A9061. 15 Jan. 2026, doi:10.3174/ajnr.A9061

BACKGROUND AND PURPOSE: Spinal CSF leaks cause spontaneous intracranial hypotension (SIH), characterized by orthostatic headaches, but the detection of these leaks may require specialized and invasive spinal imaging. We have noted the presence of small lateral dural CSF collections of unclear significance on digital subtraction myelography (DSM) in some of these patients suspected of having SIH. The purpose of the present study was to compare radiographic and anatomic intraoperative findings in patients with such small lateral dural CSF collections who underwent surgical exploration. 

MATERIALS AND METHODS: This retrospective cohort study included a consecutive group of patients suspected of having SIH who 1) did not have a spinal longitudinal extradural collection or CSF-venous fistula on spinal imaging; 2) underwent DSM under general anesthesia in the lateral decubitus position; and 3) underwent surgery for the finding of small lateral dural CSF collections of uncertain significance.  

RESULTS: The study group consisted of 27 patients (22 women and 5 men; mean age, 44.6 years; range, 16-72 years). DSM demonstrated a total of 31 small lateral dural CSF collections measuring 0.6-2.4 mm in diameter (mean, 1.3 mm) and 1.3-12.3 mm (mean, 3.5 mm) caudal to the origin of the neve root sleeve. Intraoperative exploration found evidence of a CSF leak in all 27 patients. One or more CSF-venous fistulas were found in 23 patients, and a pedicular type lateral CSF leak, in 4 patients. Radiographic differentiation between these 2 types of spinal CSF leaks could not be made with confidence.  

CONCLUSIONS: Some patients suspected of having SIH have small lateral dural CSF collections on DSM caudal to the origin of the nerve root sleeve. We have found evidence of a CSF leak in all these patients on surgical exploration. This observation expands their treatment options. 

PMID: 41539719  
DOI: 10.3174/ajnr.A9061

AUTHORS: Ajay A Madhavan, Timothy J Amrhein, Michelle L Kodet, Niklas Lützen, Michael Malinzak, Jeremy K Cutsforth-Gregory, Ian T Mark, Ivan Garza, Eike I Piechowiak, Lalani Carlton Jones

CITATION: AJNR. American journal of neuroradiology vol. 47,1 238-243. 5 Jan. 2026, doi:10.3174/ajnr.A8900

ABSTRACT: CSF-venous fistulas (CVFs) are a common cause of spontaneous intracranial hypotension. Due to the more routine use of decubitus myelography and advancements in various imaging techniques, recognition of CVFs has increased in recent years. Most commonly, patients harbor only 1 fistula at the time of myelography (although additional de novo fistulas can arise after treatment). Occasionally, 2 synchronous CVFs may be seen on a single myelogram. The coexistence of more than 2 CVFs, however, is quite rare and has only been previously described in 2 instances. Here, we present a multi-institutional series of 16 patients with 3 or more concurrently discovered CVFs, representing the largest cohort of such patients to date. We describe their clinical features, imaging findings, treatment approaches, and outcomes.

PMID: 40571346
PMCID: PMC12767699 (available on 2027-01-01)
DOI: 10.3174/ajnr.A8900