Although imaging features of suspected SIH are best visualized on MRI head without and with IV contrast, some imaging features such as midbrain descent, superficial siderosis, subdural hygroma or hematoma, convex superior surface of the pituitary, pituitary height, pontomesencephalic angle, suprasellar cistern, prepontine cistern, midbrain descent, venous-hinge angle, mamillopontine angle, tonsillar descent, and area cavum veli interpositi may be evaluated on noncontrast MRI sequences [16,25,26]. The cumulative presence of these intracranial findings has been shown to correlate with likelihood of finding a spinal leak source [16]. Radiographic Myelography Digital Subtraction Complete Spine There is no relevant literature to support the use of dynamic digital subtraction myelography in the initial imaging of suspected SIH. Dynamic digital subtraction myelography plays an important role in the subsequent imaging workup of SIH after initial brain and spine imaging [53]. Results from an initial spine MRI or conventional CT myelogram provide useful information on how a subsequent dynamic digital subtraction myelogram will be performed, such as prone positioning for suspected ventral dural defect or decubitus positioning for suspected leaking meningeal diverticulum or CSF-venous fistula [24,53,54]. Dynamic digital subtraction myelography involves continuous real-time fluoroscopic x-ray imaging of the entire spine or of a focused region of the spine where there is suspicion for CSF leak. When performed in the decubitus position, 2 separate contrast injections may be required due to the transient temporal characteristics associated with CSF-venous fistula visualization as well as limitations in contrast dosing [40-44]. Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
Imaging of Suspected Intracranial Hypotension PCAs. Although imaging features of suspected SIH are best visualized on MRI head without and with IV contrast, some imaging features such as midbrain descent, superficial siderosis, subdural hygroma or hematoma, convex superior surface of the pituitary, pituitary height, pontomesencephalic angle, suprasellar cistern, prepontine cistern, midbrain descent, venous-hinge angle, mamillopontine angle, tonsillar descent, and area cavum veli interpositi may be evaluated on noncontrast MRI sequences [16,25,26]. The cumulative presence of these intracranial findings has been shown to correlate with likelihood of finding a spinal leak source [16]. Radiographic Myelography Digital Subtraction Complete Spine There is no relevant literature to support the use of dynamic digital subtraction myelography in the initial imaging of suspected SIH. Dynamic digital subtraction myelography plays an important role in the subsequent imaging workup of SIH after initial brain and spine imaging [53]. Results from an initial spine MRI or conventional CT myelogram provide useful information on how a subsequent dynamic digital subtraction myelogram will be performed, such as prone positioning for suspected ventral dural defect or decubitus positioning for suspected leaking meningeal diverticulum or CSF-venous fistula [24,53,54]. Dynamic digital subtraction myelography involves continuous real-time fluoroscopic x-ray imaging of the entire spine or of a focused region of the spine where there is suspicion for CSF leak. When performed in the decubitus position, 2 separate contrast injections may be required due to the transient temporal characteristics associated with CSF-venous fistula visualization as well as limitations in contrast dosing [40-44]. Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.