I first met one of the patients with intracranial hypotension syndrome at Johns Hopkins Hospital during my neuroradiology research fellowship in 2000. Later on, in 2002, this case was published in AJNR.¹

After finishing my research fellowship, in my clinical practice, I realized that intracranial hypotension is not a rare syndrome. There were only 40 papers in the literature in 2000, but there are now thousands of papers available on this topic.

First, as usual, I tried to use CT myelography to detect a CSF leak in the spinal region in intracranial hypotension syndrome. However, in 2005 and 2006, my team and I did 2 radiation studies about breast radiation exposure during the CT exam^2,3; there I realized that when spinal scanning with CT myelography, a large amount of radiation is absorbed by the breasts, thyroid, and ovaries. Therefore, I thought we should find a different way, without radiation. Later, I saw a paper about CSF leak detection with gadolinium-enhanced MRI in the intracranial region, and I thought that this was a good idea, so I established my research project entitled “Gadolinium-Enhanced MR Cisternography” to evaluate dural leaks in intracranial hypotension syndrome.⁴ My paper was published in AJNR in 2008, and one of the Senior Editors, Dr. Dillon, wrote an editorial about my paper in the Journal. In addition, I received a lot of positive feedback about my paper; my colleagues around the world wanted a copy of the PDF.

From 2008 to the present, I have used gadolinium-enhanced MR cisternography to evaluate dural leaks in selected intracranial hypotension cases in young female patients, due to the radiation risks from CT myelography. However, intrathecal injection of gadolinium contrast is currently an off-label use. The other main advantage of MR cisternography is in its ability to detect slow or small leaks in intracranial hypotension syndrome.

The only drawback of gadolinium-enhanced MR cisternography has to do with artificial CSF leaks due to lumbar puncture. Radiologists should therefore be careful about interpretation due to artificial leak secondary to puncture in the lumbar region, and lumbar puncture should be nontraumatic. Another issue is spinal absorption of CSF. This concept is new, and I performed an animal study to show spinal absorption of CSF in rabbits, which was published in the Journal of Neurosurgery.⁵

In the future, I want to try to see the actual power of gadolinium-enhanced cisternography for diagnosis of CSF leaks in intracranial hypotension syndrome within a large case study, and also try to show advantages over CT myelography. I will publish my results in the future, most likely in AJNR.

References

1. Albayram S, Wasserman BA, Yousem DM, et al. Intracranial hypotension as a cause of radiculopathy from cervical epidural venous engorgement: case report. AJNR Am J Neuroradiol 2002;23:618–21
2. Yilmaz MH, Albayram S, Yaşar D, et al. Female breast radiation exposure during thorax multidetector computed tomography and the effectiveness of bismuth breast shield to reduce breast radiation dose. J Comput Assist Tomogr 2007;31:138–42. doi: 10.1097/01.rct.0000235070.50055.e6
3. Yilmaz MH, Yaşar D, Albayram S, et al. Coronary calcium scoring with MDCT: the radiation dose to the breast and the effectiveness of bismuth breast shield. Eur J Radiol 2007;61:139–43. doi: 10.1016/j.ejrad.2006.08.012
4. Albayram S, Kilic F, Ozer H, et al. Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. AJNR Am J Neuroradiol 2008;29:116–21. doi: 10.3174/ajnr.A0746
5. Biceroglu H, Albayram S, Ogullar S, et al. Direct venous spinal reabsorption of cerebrospinal fluid: a new concept with serial magnetic resonance cisternography in rabbits. J Neurosurg Spine 2012;16:394–401. doi: 10.3171/2011.12.SPINE11108

 

Read this article at AJNR.org . . .