False localizing signs of spinal CSF–venous fistulas in spontaneous intracranial hypotension: report of 2 cases

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A spinal CSF–venous fistula is one of three specific types of spinal CSF leak that can be seen in patients with spontaneous intracranial hypotension (SIH). They are best demonstrated on specialized imaging, such as digital subtraction myelography (DSM) or dynamic myelography, but often they are diagnosed on the basis of increased contrast density in the draining veins (the so-called hyperdense paraspinal vein sign) on early postmyelography CT scans. The authors report on 2 patients who underwent directed treatment (surgery in one patient and glue injection in the other) based on the hyperdense paraspinal vein sign, in whom the actual site of the fistula did not correspond to the level or laterality of the hyperdense paraspinal vein sign. The authors suggest consideration of DSM or dynamic myelography prior to undertaking treatment directed at these fistulas.

ABBREVIATIONS DSM = digital subtraction myelography; SIH = spontaneous intracranial hypotension.

Article Information

Correspondence Wouter I. Schievink: Cedars-Sinai Medical Center, Los Angeles, CA. schievinkw@cshs.org.

INCLUDE WHEN CITING Published online July 5, 2019; DOI: 10.3171/2019.4.SPINE19283.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Preoperative T1-weighted sagittal MR image (A) and Gd-enhanced axial MR image (B) showing brain sagging, pituitary enlargement, and pachymeningeal enhancement. Postoperative T1-weighted sagittal MR image (C) and Gd-enhanced axial MR image (D) showing resolution of these abnormalities.

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    Case 1. Early postmyelography CT scan showing right paraspinal hyperdense vein at the T7–8 level (arrow). Figure is available in color online only.

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    Case 1. Left lateral decubitus DSM images showing a left T7–8 CSF–venous fistula (left, arrow) with drainage exclusively to the contralateral side (right, arrow). Figure is available in color online only.

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    Case 2. Preoperative T1-weighted Gd-enhanced axial MR image (left) showing pachymeningeal enhancement. Postoperative T1-weighted Gd-enhanced axial MR image (right) showing resolution of the pachymeningeal enhancement.

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    Case 2. Left lateral decubitus DSM images showing a left T10–11 CSF–venous fistula (left, arrow) with drainage mainly superiorly to the T9–10 level (right, arrow). Figure is available in color online only.

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