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Spinal epidural CSF leak in a case of intracranial hypotension

Case contributed by Dr Christine Goh


2 weeks of postural headache.

Patient Data

Age: 49
Gender: Female

Of note, these images were obtained 30 minutes after a contrast enhanced MRI brain. An extensive extradural fluid collection involving the entire spinal canal partially effaces the thecal sac. The collection is T2 and T1 hyperintense to CSF and contains multiple engorged epidural vessels. The signal hyperintensity may be due to proteinaceous content or due to contrast accumulation.

MRI spine was performed the following day, to obtain noncontrast enhanced T1 sequences and to complete the study with T2 axial sequences.

In the absence of contrast, the extensive epidural collection is confirmed to be isointense to CSF on T1 and T2 sequences.

Diffuse smooth enhancing pachymeningeal thickening, enlargement of dural venous sinuses and plump pituitary gland are all typical features of intracranial hypotension. Nonspecific T2 hyperintense focus in left frontal white matter is incidental to presenting complaint.

Case Discussion

The spinal manifestations of spontaneous intracranial hypotension are infrequently described, and most often encountered when spinal MRI is performed to search for a site of CSF leak.

Typically MRI reveals an extensive nonfocal extradural CSF collection (spinal hygroma) that is isointense to CSF, and contains dilated epidural veins.  The dural sac usually maintains its midline attachment to the posterior longitudinal ligament with collapse of the anterolateral thecal sac, giving a 'festooned' appearance.  Smooth circumferential dural enhancement is common.  Occasionally delayed contrast leak into the collections has been described (as in this case). It is common to see a 'collection' of CSF between the spinous processes of C1 and C2.  This is a false localizing sign and should not be mistaken for the site of CSF leak.

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Case information

rID: 34576
Published: 5th Mar 2015
Last edited: 21st Oct 2020
Inclusion in quiz mode: Included

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