E1106. A Pictorial Review of Magnetic Resonance Imaging and Myelography in Spontaneous Intracranial Hypotension
  1. Ayman Nada; University of Missouri, Radiology Department
  2. Eman Mahdi; University of Missouri, Radiology Department
  3. Esmat Mahmoud; National Cancer Institute, Cairo University
  4. Joseph Cousins; University of Missouri, Radiology Department
  5. Carlos Leiva-Salinas; University of Missouri, Radiology Department
  6. Humera Ahsan; University of Missouri, Radiology Department
1. Discuss the clinical significance of spontaneous intracranial hypotension and its causes. 2. Demonstrate the diagnostic imaging workup in patients suspected of spontaneous intracranial hypotension. 3. Describe the role of MRI brain and spine in the detection and localization of CSF leakage. 4. Describe the MRI protocol with an emphasis on 3D T2 high resolution and spinal myelographic sequences. 5. Illustrate typical imaging features suggestive of CSF leakage and spontaneous intracranial hypotension.

Educational Goals / Teaching Points
1. Discuss the possible etiologies of CSF leakage and the incidence of spontaneous intracranial hypotension. 2. Describe the proper management and diagnostic workup for patients presented with headache and concerning of intracranial hypotension. 3. Enumerate the advantages and disadvantages of each imaging modality to detect and localize CSF leakage. 4. Illustrate the classic and typical intracranial findings suggestive of intracranial hypotension such as subdural collections, pacchymeningeal enhancement, and sagging of brain structures. 5. Demonstrate the reliable imaging criteria of spinal MRI to suggest CSF leakage such as epidural collections and distended epidural veins. 6. Discuss differential diagnoses, pitfalls, and mimics.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Patients with spontaneous intracranial hypotension and suspected CSF leakage present with orthostatic headache. Imaging evaluation in these patients is crucial and could depict many findings. MRI is the non-invasive imaging modality of choice for evaluation of patients suspected with intracranial hypotension. Brain findings include subdural collections, pacchymeningal enhancement, engorgement of pituitary gland and dural venous sinuses, and sagging of the midline structures with effacement of the basal CSF cisterns. Qualitative measurement of the mammillo-pontine distance and ponto-mesencephalic angle could help in diagnosis. Many spinal findings have also been described which suggest CSF leakage and include epidural collections, pseudomeningocele formation, pacchymeningeal enhancement, and prominent epidural veins. High-resolution 3D T2 imaging help to localize the site of CSF leakage in the brain or spine. Despite being invasive and radiation exposure, CT myelogram is the standard imaging modality for the detection of dural tears and localization of CSF leakage.

High-resolution 3D T2 MR myelographic sequences are helpful non-invasive imaging tool for evaluation of patients presented with orthostatic headache and suspected for spontaneous intracranial hypotension and CSF leakage.