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Table of Contents    
LETTER TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 4  |  Page : 1187-1189

Modification in MRI contrast myelogram by instillation of intrathecal preservative-free normal saline to demonstrate CSF spinal leaks


1 Department of Imaging, Kokilaben Dhirubhai Ambani Hospital and Medical Research Centre, Mumbai, Maharashtra, India
2 Department of Neurosurgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Centre, Mumbai, Maharashtra, India
3 Department of Anesthesia, Kokilaben Dhirubhai Ambani Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Web Publication18-Jul-2018

Correspondence Address:
Dr. Abhijeet Walavalkar
Department of Imaging, Kokilaben Dhirubhai Ambani Hospital and Medical Research Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.237023

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How to cite this article:
Kootar S, Walavalkar A, Kumar A, Bhave C, Sanghvi D. Modification in MRI contrast myelogram by instillation of intrathecal preservative-free normal saline to demonstrate CSF spinal leaks. Neurol India 2018;66:1187-9

How to cite this URL:
Kootar S, Walavalkar A, Kumar A, Bhave C, Sanghvi D. Modification in MRI contrast myelogram by instillation of intrathecal preservative-free normal saline to demonstrate CSF spinal leaks. Neurol India [serial online] 2018 [cited 2018 Nov 18];66:1187-9. Available from: http://www.neurologyindia.com/text.asp?2018/66/4/1187/237023




Sir,

We would like to inform you about a modification in magnetic resonance imaging (MRI) contrast myelograms by instillation of intrathecal preservative-free normal saline to increase spinal pressure. This modification has an incremental value in the demonstration of spinal cerebrospinal fluid (CSF) leaks compared to the conventional techniques.

A female patient aged 54 years presented with headache. She was operated for bilateral subdural hematomas but returned complaining of recurrent orthostatic headaches. A repeat computed tomography (CT) of the brain showed bilateral subdural collections and a mass effect on the brain with uncal and early tonsillar herniation. A 3-Tesla MRI of the brain with noncontrast myelogram (3D SPACE [Three dimensional Sampling Perfection with Application optimized Contrasts using different flip angle Evolution]) was performed. In addition to the findings on CT scan, MRI showed diffuse pachymeningeal enhancement, prominent dural venous sinuses, enlarged pituitary gland, prominent epidural space in the spine, and edema in the upper cervical paraspinal muscles [Figure 1]. These features were representative of intracranial hypotension.[1] However, the site of leak could not be demonstrated on noncontrast magnetic resonance imaging (MRI) myelogram. As the patient continued to have worsening postural headaches, the referring neurosurgeon requested for a contrast myelogram to detect the site of cerebrospinal fluid (CSF) leak.
Figure 1: Sagittal T2 weighted (a) and axial contrast T1 weighted (b) MRI brain showing low lying tonsils (white arrow), sagging of brainstem, bilateral subdural collections, compressed lateral ventricles and extensive pachymeningeal enhancement suggestive of intracranial hypotension

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Following the lumbar puncture, a manometer was attached to a three-way stopcock to measure the opening CSF pressure. 0.5 ml of gadolinium contrast in 5 ml normal saline was instilled into the thecal sac followed by continuous infusion of 70 ml of normal saline at a rate of 1 ml/min till CSF pressure increased to 14 cm of water. Instillation was stopped when the patient complained of tingling and numbness in the lower limbs.

Postcontrast T1-weighted axial and sagittal MRI showed multiple posterior and left lateral cervical dural diverticuli. CSF leak was identified in the C4–5 interspinous space [Figure 2].
Figure 2: Sagittal (a) and axial (b and c) contrast MR myelography shows multiple posterior dural diverticuli. CSF leak was demonstrated in the C4-C5 interspinous space (white arrow) with contrast extravasation in the posterior paraspinal soft tissues (white dotted arrows)

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The conventional MR myelography fails to identify a significant proportion of CSF leaks (63–79%).[1],[2] The reasons are variable and include transient CSF leaks, low pressure CSF leaks caused by very low intrathecal pressure, and very small leaks.[2] To overcome these limitations, a modification of the conventional contrast-enhanced MR myelogram involves artificially increasing the intrathecal pressure by infusing preservative-free normal saline into the thecal sac. Increasing thecal sac pressure improves the probability for CSF to actively leak across the dural tear during imaging and thus improving the demonstration of extravasation after administration of intrathecal gadolinium.[3] Accurate demonstration of the level of CSF leak facilitates effective treatment by an autologous epidural blood patch.

A review of case records in the study conducted by Griauzde et al.,[3] among patients who underwent preservative-free normal saline challenge coupled with contrast-enhanced MR myelography showed CSF leaks in 4 out of 5 patients with a previously normal computed tomographic (CT) myelogram. Additional leaks were identified in another patient who had shown a single leak on a previous CT myelogram.

To conclude, intrathecal instillation of saline infusion has an incremental value in the demonstration of spinal CSF leaks, compared to conventional MR myelograms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chazen JL, Talbott JF, Lantos JE, Dillon WP. MR myelography for identification of spinal CSF leak in spontaneous intracranial hypotension. Am J Neuroradiol 2014;35:2007-12.  Back to cited text no. 1
    
2.
Akbar JJ, Luetmer PH, Schwartz KM, Hunt CH, Diehn FE, Eckel LJ. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. Am J Neuroradiol 2012;33:535-40.  Back to cited text no. 2
    
3.
Griauzde J, Gemmete JJ, Pandey AS, Chaudhary N. Intrathecal preservative-free normal saline challenge magnetic resonance myelography for the identification of cerebrospinal fluid leaks in spontaneous intracranial hypotension. J Neurosurg 2015;123:732-6.  Back to cited text no. 3
    


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