Craniospinal hypotension CSF leak

Case contributed by Assoc Prof Frank Gaillard


5 year history of intermittent headache.

Patient Data

Age: 40 years
Gender: Female

Inferior descent of the cerebellar tonsils by approximately 12 mm bilaterally, with sagging midbrain and effacement of the prepontine cistern. There is crowding of the suprasellar cistern, with the optic chiasm draped over the budgetary gland. The pituitary is plump and protrudes approximately 4 mm above the sella. No focal pituitary lesions are demonstrated, and the posterior pituitary bright spot is preserved.

Post-contrast images demonstrate diffuse, smooth enhancement of the dura, with no nodularity or focal mass lesion. No dural venous sinus and gorge within the cranial cavity, but the anterior epidural venous plexus is in the upper part of the neck are engorged . The ventricles and sulci age appropriate. No diffusion restriction.


The findings are highly suggestive of intracranial hypotension.


CT of the lumbar, thoracic and cervical spine following intrathecal injection of contrast.

The cerebellar tonsils extend 1cm beyond the foramen magnum.

There is epidural contrast within the epidural space of the entire spine from lumbar to base of skull. In the cervical region, contrast is seen extending beyond the epidural space at multiple levels: at the left around the lower three cervical nerve roots (C6-8) and posteriorly at the C1/2 level.

Some contrast is seen within the subdural space in the lower lumbar spine, which relates to the initial contrast injection during fluoroscopy. 

Nuclear medicine


These studies show a large, initially bilateral leak at approximately the cervicothoracic and/or T1-2 junction consistent with a large CSF leak.

No other abnormalities are detected in the thoracic or lumbar or cervical theca.

No obvious CSF leak is seen in the head.

Case Discussion

This case illustrates a high volume leak, making localization of the actual leak difficult. One should refrain from interpreting areas of contrast extending beyond the epidural space as being localizing in the setting of abundant epidural contrast. 

Rather, a scan with temporal high resolution should be performed, or treatment with a lumbar epidural can be performed speculatively. The latter was performed in this case, and the patient became, and has remained symptom free.

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