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Images in Neurology |

Detection of Cerebrospinal Fluid Leaks by Intrathecal Contrast-Enhanced Magnetic Resonance Myelography

Athina Papadopoulou, MD1; Frank-Johannes Ahlhelm, MD2; Stephan Ulmer, MD2; Ludwig Kappos, MD1; Till Sprenger, MD1,2
[+] Author Affiliations
1Department of Neurology, University Hospital Basel, Basel, Switzerland
2Division of Diagnostic and Interventional Neuroradiology, Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
JAMA Neurol. 2013;70(12):1576-1577. doi:10.1001/jamaneurol.2013.744.
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A 70-year-old woman had double vision, nausea, neck pain, and acute bilateral hypacusis. The neurological examination showed nerve VI palsy on the right. There was no history of trauma. Brain magnetic resonance (MR) imaging was indicative of intracranial hypotension, with diffuse pachymeningeal thickening, strong dural enhancement, and frontoparietal subdural hygromas. A radioisotope cisternography, performed in the search for a potential spinal cerebrospinal fluid (CSF) leak, was inconclusive. Thus, intrathecal gadolinium-enhanced MR myelography was considered as a possible alternative. Before intrathecal gadolinium administration, an MR image of the spinal cord showed a small perineural cyst at the level of L2 on the right but no evidence of a CSF leakage. The intrathecal gadolinium-enhanced MR myelography provided clear-cut evidence of dural leaks along the right L2 and L3 nerve roots (Figure). According to these findings, targeted epidural blood patching was performed and the patient’s symptoms gradually improved during the following month. At 1-year follow-up, she was asymptomatic.

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Figure.
T1-Weighted Fat-Suppressed Magnetic Resonance Images, Performed 1 Hour After Intrathecal Administration of Gadolinium (Contrast-Enhanced Magnetic Resonance Myelography)

A, Coronal image showing extradural contrast enhancement and enhancement along the right L2 and L3 nerve roots (arrowheads), representing the cerebrospinal fluid leaks. B, Coronal image 3.5 mm posterior to part A. C, Axial image at the L2 level, showing the enhancement along the L2 nerve root (arrowhead). D, Axial image at the L3 level, showing the enhancement along the L3 nerve root (arrowhead).

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