Diagnostic Yield of Lateral Decubitus Digital Subtraction Myelogram Stratified by Brain MRI Findings
Abstract
Objective
To assess the diagnostic yield of lateral decubitus digital subtraction myelography (LDDSM) and stratify LDDSM diagnostic yield by the Bern spontaneous intracranial hypotension (SIH) score of preprocedure brain MRI.
Methods
This retrospective diagnostic study included consecutive adult patients investigated for SIH who underwent LDDSM. Patients without preprocedure brain and spine MRI and patients with extradural fluid collection on spine MRI (type 1 leak) were excluded. LDDSM images and brain MRIs were assessed by 2 independent blinded readers; a third reader adjudicated any discrepancies. Diagnostic yield of LDDSM was assessed, both overall and stratified by Bern SIH scoring.
Results
Of the 62 patients included in this study, 33 (53.2%) had a CSF leak identified on LDDSM. Right-sided leaks were more common (70.6%), and the most commonly identified levels of leaks were at T6, T7, and T10. No leak was found in any of the 9 patients with Bern SIH score of 2 or less. Of the 11 patients with Bern SIH score of 3–4, 5 (45.5%) had a CSF leak identified; of the 42 patients with Bern SIH score of 5 or higher, 28 (66.7%) had a CSF leak identified.
Conclusions
LDDSM has a high diagnostic yield for finding the exact location of spinal CSF leak, and the diagnostic yield increases with higher Bern SIH score. No leaks were found in patients with Bern SIH score of 2 or less, suggesting that foregoing invasive testing such as LDDSM in these patients may be appropriate unless accompanied by high clinical suspicion.
Classification of Evidence
This study provides Class II evidence that for patients with suspected SIH, higher Bern SIH scores are associated with a greater likelihood of LDDSM-identified CSF leaks.
Get full access to this article
View all available purchase options and get full access to this article.
References
1.
Davidson B, Nassiri F, Mansouri A, et al. Spontaneous intracranial hypotension: a review and introduction of an algorithm for management. World Neurosurg 2017;101:343–349.
2.
Dobrocky T, Grunder L, Breiding PS, et al. Assessing spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension with a scoring system based on brain magnetic resonance imaging findings. JAMA Neurol 2019;76:580–587.
3.
Kim DK, Brinjikji W, Morris PP, et al. Lateral decubitus digital subtraction myelography: tips, tricks, and pitfalls. AJNR Am J Neuroradiol 2020;41:21–28.
4.
Farb RI, Nicholson PJ, Peng PW, et al. Spontaneous intracranial hypotension: a systematic imaging approach for CSF leak localization and management based on MRI and digital subtraction myelography. AJNR Am J Neuroradiol 2019;40:745–753.
5.
Schievink WI, Maya MM, Moser FG, et al. Lateral decubitus digital subtraction myelography to identify spinal CSF-venous fistulas in spontaneous intracranial hypotension. J Neurosurg Spine 2019;1–4.
6.
Thielen KR, Sillery JC, Morris JM, et al. Ultrafast dynamic computed tomography myelography for the precise identification of high-flow cerebrospinal fluid leaks caused by spiculated spinal osteophytes. J Neurosurg Spine 2015;22:324–331.
7.
Luetmer PH, Schwartz KM, Eckel LJ, Hunt CH, Carter RE, Diehn FE. When should I do dynamic CT myelography? Predicting fast spinal CSF leaks in patients with spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2012;33:690–694.
8.
Hoxworth JM, Patel AC, Bosch EP, Nelson KD. Localization of a rapid CSF leak with digital subtraction myelography. AJNR Am J Neuroradiol 2009;30:516–519.
9.
Fishman RA, Dillon WP. Dural enhancement and cerebral displacement secondary to intracranial hypotension. Neurology 1993;43:609–611.
10.
Pannullo SC, Reich JB, Krol G, Deck MD, Posner JB. MRI changes in intracranial hypotension. Neurology 1993;43:919–926.
11.
Kranz PG, Amrhein TJ, Choudhury KR, Tanpitukpongse TP, Gray L. Time-dependent changes in dural enhancement associated with spontaneous intracranial hypotension. AJR Am J Roentgenol 2016;207:1283–1287.
12.
Schievink WI, Moser FG, Maya MM, Prasad RS. Digital subtraction myelography for the identification of spontaneous spinal CSF-venous fistulas. J Neurosurg Spine 2016;24:960–964.
13.
Starling A, Hernandez F, Hoxworth JM, et al. Sensitivity of MRI of the spine compared with CT myelography in orthostatic headache with CSF leak. Neurology 2013;81:1789–1792.
Information & Authors
Information
Published In
Copyright
© 2021 American Academy of Neurology.
Publication History
Received: June 14, 2020
Accepted: November 2, 2020
Published online: January 20, 2021
Published in print: March 2, 2021
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Study Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors
Metrics & Citations
Metrics
Citations
Download Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.
Cited By
- Bern score, Radiopaedia.org, (2024).https://doi.org/10.53347/rID-184103
- Skull Base CSF Leaks: Potential Underlying Pathophysiology and Evaluation of Brain MR Imaging Findings Associated with Spontaneous Intracranial Hypotension, American Journal of Neuroradiology, (2024).https://doi.org/10.3174/ajnr.A8333
- Myelographic Techniques for the Localization of CSF-Venous Fistulas: Updates in 2024, American Journal of Neuroradiology, (2024).https://doi.org/10.3174/ajnr.A8299
- Volumetric Changes in the Choroid Plexus Associated with Spontaneous Intracranial Hypotension in Patients with Spinal CSF Leak, American Journal of Neuroradiology, 45, 8, (1162-1165), (2024).https://doi.org/10.3174/ajnr.A8291
- The Spatial Relationship between Spinal Osteoarthritis and CSF Venous Fistulas in Patients with Spontaneous Intracranial Hypotension, American Journal of Neuroradiology, 45, 7, (957-960), (2024).https://doi.org/10.3174/ajnr.A8247
- Perspectives from the Inaugural “Spinal CSF Leak: Bridging the Gap” Conference: A Convergence of Clinical and Patient Expertise, American Journal of Neuroradiology, 45, 7, (841-849), (2024).https://doi.org/10.3174/ajnr.A8181
- Long-Term Epidural Patching Outcomes and Predictors of Benefit in Patients With Suspected CSF Leak Nonconforming to ICHD-3 Criteria, Neurology, 102, 12, (2024)./doi/10.1212/WNL.0000000000209449
- Diagnosis and Treatment of Spontaneous Intracranial Hypotension, Neurology Clinical Practice, 14, 3, (2024)./doi/10.1212/CPJ.0000000000200290
- Patterns of clinical and imaging presentations in patients with spontaneous intracranial hypotension due to spinal cerebrospinal fluid venous fistula: A single‐center retrospective cross‐sectional study, Headache: The Journal of Head and Face Pain, 64, 8, (939-949), (2024).https://doi.org/10.1111/head.14805
- Beyond myths: Transformative insights into spinal cerebrospinal fluid leaks and their role in persistent headache syndromes, Headache: The Journal of Head and Face Pain, 64, 3, (229-232), (2024).https://doi.org/10.1111/head.14677
- See more
Loading...
View Options
Login options
Check if you have access through your login credentials or your institution to get full access on this article.
Personal login Institutional LoginPurchase Options
The neurology.org payment platform is currently offline. Our technical team is working as quickly as possible to restore service.
If you need immediate support or to place an order, please call or email customer service:
- 1-800-638-3030 for U.S. customers - 8:30 - 7 pm ET (M-F)
- 1-301-223-2300 for customers outside the U.S. - 8:30 - 7 pm ET (M-F)
- [email protected]
We appreciate your patience during this time and apologize for any inconvenience.