Dong Kun Kim

Our institution has a very active practice on the diagnosis and treatment of spontaneous intracranial hypotension. Our neuroradiology division has a group of 9 neuroradiologists who routinely perform diagnostic procedures and therapeutic interventions specific to spontaneous spinal CSF leak (SSCSFL). We also have a headache clinic run by the neurology department where patients are often referred to neuroradiology for diagnosis and intervention, and a team of neurosurgeons who are experts in surgical treatment options. This comprehensive model of dedicated neuroradiologists, neurologists, and neurosurgeons working together to provide the best care for patients with SSCSFL has resulted in excellent clinical care and a distinguished reputation driving the patient referrals.

Over the years, we have performed various diagnostic procedures to better diagnose SSCSFL, and when we adopted lateral decubitus digital subtraction myelography (DSM) in 2018, we found improved diagnostic yield and confidence in finding SSCSFL, similar to reports by Farb et al and Schievink et al.^1,2 We also noticed that, unlike many radiologic diagnostic examinations, operator technique is essential for diagnostic confidence, and due to the daily maximum intrathecal dose of Omnipaque 300, if the technique is suboptimal, repeat exam needs to be performed on a separate day. Given how essential operator technique is to lateral decubitus DSM, we wanted to share our experience to obtain the best possible quality examination.

The 9 neuroradiologists who routinely perform spine procedures have worked very closely to improve the lateral decubitus DSM technique to optimize diagnostic yield and confidence of the examinations since 2018. The technique shown in the paper is our current consensus on how the exams should be performed, but we are continuously finding ways to improve our protocol to better serve our patients.

We received much positive feedback from radiologists in other institutions who specialize in the diagnosis and treatment of SSCSFL, and also from community radiologists who do not routinely perform these procedures but are aware of secondary MRI findings of SSCSFL. Several non-neuroradiology colleagues also commented on the excellent quality of the diagnostic images in the manuscript.

Recently, we have looked into the diagnostic yield of lateral decubitus DSM in finding the exact site of the leak, which will be presented at the American Society of Neuroradiology 2020 Annual Meeting. Other ongoing projects include patients’ clinical and imaging improvement from targeted interventions following positive lateral decubitus DSM exams. Also, as the etiology of CSF venous fistula is still unclear, we are looking into a potential association between various syndromic pathologies and CSF venous fistula, which could elucidate the potential pathogenesis of CSF fistula.³ By working closely with our neurology and neurosurgery colleagues, we hope to expand our research on this subject to better understand, diagnose, and treat SSCSFL to better serve patients with this underdiagnosed yet potentially debilitating cause of headache.

References

1. Farb RI, Nicholson PJ, Peng PW, et al. Spontaneous intracranial hypotension: a systematic imaging approach for CSF leak localization and management based on MRI and digital subtraction myelography. AJNR Am J Neuroradiol 2019;40:745–53, 10.3174/ajnr.A6016
2. Schievink WI, Maya MM, Moser FG, et al. Lateral decubitus digital subtraction myelography to identify spinal CSF-venous fistulas in spontaneous intracranial hypotension. J Neurosurg Spine 2019;31:902–05, 10.3171/2019.6.SPINE19487
3. Madhavan AA, Kim DK, Brinjikji W, et al. Diagnosis of a cerebrospinal fluid-venous fistula associated with a venous malformation using digital subtraction and computed tomography myelography. World Neurosurg 2019;135:262–66, 10.1016/j.wneu.2019.12.075

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