Niklas Lützen, Horst Urbach, Florian Volz, Amir El Rahal, Katharina Wolf, Laura Krismer, Jürgen Beck, Charlotte Zander
{"title":"数字减影脊髓造影显示2型脊髓脊液外侧漏的时间特征:快速、中速还是慢速漏?","authors":"Niklas Lützen, Horst Urbach, Florian Volz, Amir El Rahal, Katharina Wolf, Laura Krismer, Jürgen Beck, Charlotte Zander","doi":"10.3174/ajnr.A9040","DOIUrl":null,"url":null,"abstract":"<p><strong>Background and purpose: </strong>Type 2 leaks occur in up to 20% of spontaneous intracranial hypotension (SIH) due to a spinal lateral dural tear, typically accompanied by arachnoid hernia. Their CSF-outflow dynamics are unclear, but could have implications on performing myelography for best possible detection. This cross-sectional study analyzed temporal characteristics of type 2 leaks using digital subtraction myelography (DSM).</p><p><strong>Materials and methods: </strong>Between February 2020 and April 2025, 63 consecutive patients with type 2 leaks were retrospectively identified. Patients undergoing sufficient decubitus DSM (comprising additional fluoroscopy and X-ray images) were included. We assessed the time for the contrast agent to first appear in the epidural space after reaching the level of the leak intrathecally at 1-2 frames-per-second (fps), and categorized them as fast (0-9 sec), medium (10-90 sec), and slow (>90 sec) leaks. Furthermore, effects of intrathecal pressurization, arachnoid hernia size, opening pressure and symptom-duration on CSF-outflow were studied.</p><p><strong>Results: </strong>Forty-five patients (36 women) were included. Mean age was 39.0 years (SD ± 11.4 years), mean BMI 23.2 (SD ± 3.9) and median Bern score 6 (IQR 5). Type 2 leaks most commonly occurred at the T10/11 level (12/45; 26.7%) ranging between T7/8 -L1/2. During DSM, contrast appeared in the epidural space within 0-9 sec in 3/45 (6.7%), 10-90 sec in 24/45 (53.3%) and >90 sec in 5/45 (11,1%) of cases (range: 4 to 473 sec). If DSM (or fluoroscopy/X-ray) missed the leak, subsequent cone-beam or CT myelography detected it (13/45; 28.9%); total slow leaks were 18/45 (40%). All patients undergoing surgery (40/45) had the leak confirmed intraoperatively. In a subgroup of patients undergoing pressurization during DSM (12/45), there were significantly more leaks detected within 90s (p=0.02), while arachnoid hernia size, opening pressure and symptom duration did not affect CSF-outflow significantly.</p><p><strong>Conclusions: </strong>Type 2 leaks show a wide range of CSF-outflow characteristics, with most being medium and slow. For DSM, we propose using a 90-second run with intrathecal pressurization and cone-beam CT standby for effective leak detection, whereas less than 1 fps (e.g., 0.5 fps) seems feasible to minimize radiation. Alternatively, dynamic CT myelography can be considered -although timing of CT scans has yet to be evaluated.</p><p><strong>Abbreviations: </strong>SIH=spontaneous intracranial hypotension; DSM (digital subtraction myelography); CB-CTM (Cone-beam CT myelography); EID-CTM (energy-integrating detector CT myelography).</p>","PeriodicalId":93863,"journal":{"name":"AJNR. American journal of neuroradiology","volume":" ","pages":""},"PeriodicalIF":0.0000,"publicationDate":"2025-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Temporal Characteristics of Type 2 Lateral Spinal CSF Leaks on Digital Subtraction Myelography: Fast, Medium or Slow Leaks?\",\"authors\":\"Niklas Lützen, Horst Urbach, Florian Volz, Amir El Rahal, Katharina Wolf, Laura Krismer, Jürgen Beck, Charlotte Zander\",\"doi\":\"10.3174/ajnr.A9040\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background and purpose: </strong>Type 2 leaks occur in up to 20% of spontaneous intracranial hypotension (SIH) due to a spinal lateral dural tear, typically accompanied by arachnoid hernia. Their CSF-outflow dynamics are unclear, but could have implications on performing myelography for best possible detection. This cross-sectional study analyzed temporal characteristics of type 2 leaks using digital subtraction myelography (DSM).</p><p><strong>Materials and methods: </strong>Between February 2020 and April 2025, 63 consecutive patients with type 2 leaks were retrospectively identified. Patients undergoing sufficient decubitus DSM (comprising additional fluoroscopy and X-ray images) were included. We assessed the time for the contrast agent to first appear in the epidural space after reaching the level of the leak intrathecally at 1-2 frames-per-second (fps), and categorized them as fast (0-9 sec), medium (10-90 sec), and slow (>90 sec) leaks. Furthermore, effects of intrathecal pressurization, arachnoid hernia size, opening pressure and symptom-duration on CSF-outflow were studied.</p><p><strong>Results: </strong>Forty-five patients (36 women) were included. Mean age was 39.0 years (SD ± 11.4 years), mean BMI 23.2 (SD ± 3.9) and median Bern score 6 (IQR 5). Type 2 leaks most commonly occurred at the T10/11 level (12/45; 26.7%) ranging between T7/8 -L1/2. During DSM, contrast appeared in the epidural space within 0-9 sec in 3/45 (6.7%), 10-90 sec in 24/45 (53.3%) and >90 sec in 5/45 (11,1%) of cases (range: 4 to 473 sec). If DSM (or fluoroscopy/X-ray) missed the leak, subsequent cone-beam or CT myelography detected it (13/45; 28.9%); total slow leaks were 18/45 (40%). All patients undergoing surgery (40/45) had the leak confirmed intraoperatively. In a subgroup of patients undergoing pressurization during DSM (12/45), there were significantly more leaks detected within 90s (p=0.02), while arachnoid hernia size, opening pressure and symptom duration did not affect CSF-outflow significantly.</p><p><strong>Conclusions: </strong>Type 2 leaks show a wide range of CSF-outflow characteristics, with most being medium and slow. For DSM, we propose using a 90-second run with intrathecal pressurization and cone-beam CT standby for effective leak detection, whereas less than 1 fps (e.g., 0.5 fps) seems feasible to minimize radiation. Alternatively, dynamic CT myelography can be considered -although timing of CT scans has yet to be evaluated.</p><p><strong>Abbreviations: </strong>SIH=spontaneous intracranial hypotension; DSM (digital subtraction myelography); CB-CTM (Cone-beam CT myelography); EID-CTM (energy-integrating detector CT myelography).</p>\",\"PeriodicalId\":93863,\"journal\":{\"name\":\"AJNR. American journal of neuroradiology\",\"volume\":\" \",\"pages\":\"\"},\"PeriodicalIF\":0.0000,\"publicationDate\":\"2025-10-10\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"AJNR. 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Temporal Characteristics of Type 2 Lateral Spinal CSF Leaks on Digital Subtraction Myelography: Fast, Medium or Slow Leaks?
Background and purpose: Type 2 leaks occur in up to 20% of spontaneous intracranial hypotension (SIH) due to a spinal lateral dural tear, typically accompanied by arachnoid hernia. Their CSF-outflow dynamics are unclear, but could have implications on performing myelography for best possible detection. This cross-sectional study analyzed temporal characteristics of type 2 leaks using digital subtraction myelography (DSM).
Materials and methods: Between February 2020 and April 2025, 63 consecutive patients with type 2 leaks were retrospectively identified. Patients undergoing sufficient decubitus DSM (comprising additional fluoroscopy and X-ray images) were included. We assessed the time for the contrast agent to first appear in the epidural space after reaching the level of the leak intrathecally at 1-2 frames-per-second (fps), and categorized them as fast (0-9 sec), medium (10-90 sec), and slow (>90 sec) leaks. Furthermore, effects of intrathecal pressurization, arachnoid hernia size, opening pressure and symptom-duration on CSF-outflow were studied.
Results: Forty-five patients (36 women) were included. Mean age was 39.0 years (SD ± 11.4 years), mean BMI 23.2 (SD ± 3.9) and median Bern score 6 (IQR 5). Type 2 leaks most commonly occurred at the T10/11 level (12/45; 26.7%) ranging between T7/8 -L1/2. During DSM, contrast appeared in the epidural space within 0-9 sec in 3/45 (6.7%), 10-90 sec in 24/45 (53.3%) and >90 sec in 5/45 (11,1%) of cases (range: 4 to 473 sec). If DSM (or fluoroscopy/X-ray) missed the leak, subsequent cone-beam or CT myelography detected it (13/45; 28.9%); total slow leaks were 18/45 (40%). All patients undergoing surgery (40/45) had the leak confirmed intraoperatively. In a subgroup of patients undergoing pressurization during DSM (12/45), there were significantly more leaks detected within 90s (p=0.02), while arachnoid hernia size, opening pressure and symptom duration did not affect CSF-outflow significantly.
Conclusions: Type 2 leaks show a wide range of CSF-outflow characteristics, with most being medium and slow. For DSM, we propose using a 90-second run with intrathecal pressurization and cone-beam CT standby for effective leak detection, whereas less than 1 fps (e.g., 0.5 fps) seems feasible to minimize radiation. Alternatively, dynamic CT myelography can be considered -although timing of CT scans has yet to be evaluated.