Conebeam CT as an Adjunct to Digital Subtraction Myelography for Detection of CSF-Venous Fistulas

A.A. Madhavan; J.K. Cutsforth-Gregory; J.C. Benson; W. Brinjikji; I.T. Mark; J.T. Verdoorn

doi:10.3174/ajnr.A7794

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FIG 1.
A 52-year-old woman with years of orthostatic headaches and brain MR imaging demonstrating brain sag and pachymeningeal enhancement. Right lateral decubitus DSM (A) shows a large, right T10 meningeal diverticulum (A, dashed arrow), but no venous opacification was seen on dynamic imaging. Axial (B) and sagittal (C) images from CBCT obtained during contrast injection demonstrate subtle opacification of intramuscular venous branches (B and C, arrows) adjacent to the diverticulum (B and C, dashed arrows), compatible with CSF-venous fistula. Sagittal 50-keV monoenergetic reconstruction from right lateral decubitus CT obtained 15 minutes later (D) no longer shows opacification of these veins in the same location (D, arrow). The patient was treated with transvenous Onyx embolization of the right T10 fistula, with complete resolution of symptoms in 3 months.
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FIG 2.
A 56-year-old woman with several months of orthostatic headaches. Brain MR imaging (not shown) demonstrated brain sag and pachymeningeal enhancement. Unsubtracted image from right lateral decubitus DSM (A) shows a prominent right T6 meningeal diverticulum (A, arrow), with subtle flickering density along the lateral edge of the diverticulum during dynamic imaging. Axial (B) and sagittal (C) images from CBCT obtained during contrast injection demonstrate opacification of the right T6 paraspinal vein (B and C, solid arrows), distinct from the diverticulum (B and C, dashed arrows), overall compatible with CSF-venous fistula. Axial 50-keV reconstruction from delayed right lateral decubitus CT obtained 15 minutes later (D) shows a prominent right T6 meningeal diverticulum (D, dashed arrow) without convincing venous contrast. Transvenous Onyx embolization of the right T6 fistula is pending.
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FIG 3.
A 66-year-old man with many years of orthostatic headaches that improved after surgical treatment of a left T10 CSF-venous fistula and then recurred. Left lateral decubitus DSM (A) shows a mildly prominent left T10 meningeal diverticulum (A, arrow), with no definite venous contrast on dynamic imaging. Minimal hyperdensity seen adjacent to the diverticulum (A, dashed arrow) was initially thought to be artifactual, secondary to motion or a multilobed diverticulum. CBCT was performed to further investigate the finding. Axial (B) and sagittal (C) images from CBCT obtained during contrast injection demonstrate opacification of numerous left T10 foraminal veins (B and C, arrows), compatible with CSF-venous fistula. Axial 50-keV reconstruction from a delayed left lateral decubitus CT obtained 20 minutes later (D) shows a prominent left T10 meningeal diverticulum (D, arrow) without convincing venous contrast. The patient was treated with transvenous Onyx embolization of the left T10 fistula, with complete resolution of symptoms in 3 months.