Craniospinal hypotension and leak

Case contributed by A.Prof Frank Gaillard

Presentation

Postural headaches.

Patient Data

Age: 40 years
Gender: Female
Modality: MRI

Selected images from an MRI demonstrate uniform pachymeningeal thickening and enhancement. The superior sagittal sinus posteriorly appears enlarged / rounded. 

CT myelogram

Modality: CT

Under fluoroscopic guidance, a lumbar puncture was done at L3/4 and 12 mL of omnipaque 240 was injected.

Extensive epidural contrast from the lower thoracic region up to the base of skull. At C1/2 contrast seen extending into the paraspinal musculature posteriorly. This is known as a false localising sign and does not represent the site of leakage. 

Case Discussion

The patient had already had a lumbar epidural blood patch prior to this study, which had not been successful. A repeat blood patch following confirmation that there was indeed a substantial leak, was successful even though a definitive location was not identified on this study: a bony spur was found in the mid thoracic region from a facet joint which significantly distorted the theca, and may have been the cause. 

An alternative approach would have been to perform a high temporal resolution study, such as digital subtraction myelography or a repeat CT myelogram with injection of intrathecal contrast on the table. 

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Case Information

rID: 43085
Case created: 23rd Feb 2016
Last edited: 30th Aug 2016
Inclusion in quiz mode: Included

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