Intravenous Contrast-Enhanced MR Myelography in CSF Leakage for the Detection of Spinal CSF Lamellae

Abstract

Background and purpose: Intracranial hypotension (IH) results from cerebrospinal fluid (CSF) leakage from the dural sac, occurring spontaneously or iatrogenically (e.g., post-lumbar puncture), and may cause a wide range of symptoms with significant functional impairment. Accurate detection of the epidural CSF lamella is key to diagnosis. This study evaluated the diagnostic value of intravenous contrast-enhanced MRI using heavily T2-weighted FLAIR (HT2-FLAIR) spine imaging compared to nonenhanced MR myelography at 3 Tesla.

Methods: Ten consecutive patients with IH symptoms were prospectively examined using HT2-FLAIR imaging of the spine before and up to 3 h after gadolinium-based contrast agent administration, alongside noncontrast MR myelography. Two readers assessed the conspicuity of the CSF lamella on contrast-enhanced HT2-FLAIR (ceHT2-FLAIR) using a score from -2 to +2 and evaluated additional diagnostic benefit.

Results: A CSF lamella was seen in eight of 10 patients as a strongly enhancing band on ceHT2-FLAIR. In one case, the lamella was visible exclusively on ceHT2-FLAIR (conspicuity score [CS] = 2, n = 1) and was more conspicuous in three cases (CS = 1, n = 3). Six cases showed equal conspicuity (CS = 0, n = 6). In two cases each, ceHT2-FLAIR either enabled diagnosis or provided supporting information. In six cases, it confirmed diagnosis based on noncontrast imaging. Beyond improved conspicuity, ceHT2-FLAIR helped detect low-flow leaks, optimize axial slice positioning, and assess CSF lamella distribution.

Conclusions: Intravenous ceHT2-FLAIR MRI may be considered as an additional tool in CSF leak evaluation, particularly when used for detecting indirect signs of IH.

Keywords: CSF leakage; epidural lamella; heavily T2‐weighted (HT2) FLAIR imaging; intracranial hypotension; spinal CSF lamella.