Intravenous Contrast-Enhanced MR Myelography in CSF Leakage for the Detection of Spinal CSF Lamellae

Background and Purpose

Intracranial hypotension (IH) results from cerebrospinal fluid (CSF) leakage from the dural sac, occurring spontaneously or iatrogenically (e.g., post-lumbar puncture), and may cause a wide range of symptoms with significant functional impairment. Accurate detection of the epidural CSF lamella is key to diagnosis. This study evaluated the diagnostic value of intravenous contrast-enhanced MRI using heavily T2-weighted FLAIR (HT2-FLAIR) spine imaging compared to nonenhanced MR myelography at 3 Tesla.

Methods

Ten consecutive patients with IH symptoms were prospectively examined using HT2-FLAIR imaging of the spine before and up to 3 h after gadolinium-based contrast agent administration, alongside noncontrast MR myelography. Two readers assessed the conspicuity of the CSF lamella on contrast-enhanced HT2-FLAIR (ceHT2-FLAIR) using a score from −2 to +2 and evaluated additional diagnostic benefit.

Results

A CSF lamella was seen in eight of 10 patients as a strongly enhancing band on ceHT2-FLAIR. In one case, the lamella was visible exclusively on ceHT2-FLAIR (conspicuity score [CS] = 2, n = 1) and was more conspicuous in three cases (CS = 1, n = 3). Six cases showed equal conspicuity (CS = 0, n = 6). In two cases each, ceHT2-FLAIR either enabled diagnosis or provided supporting information. In six cases, it confirmed diagnosis based on noncontrast imaging. Beyond improved conspicuity, ceHT2-FLAIR helped detect low-flow leaks, optimize axial slice positioning, and assess CSF lamella distribution.

Conclusions

Intravenous ceHT2-FLAIR MRI may be considered as an additional tool in CSF leak evaluation, particularly when used for detecting indirect signs of IH.