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Congress: ECR26
Poster Number: C-15437
Type: Poster: EPOS Radiologist (educational)
Authorblock: R. C. Mezacasa Júnior1, A. Moraes de Souza2, L. Martins Leal da Silva2, L. Gonçalves Campos2, L. Scotta Cabral2, J. Ávila Duarte2; 1Lajeado/BR, 2Porto Alegre/BR
Disclosures:
Rudinei Carlos Mezacasa Júnior: Nothing to disclose
Adolfo Moraes de Souza: Nothing to disclose
Leopoldo Martins Leal da Silva: Nothing to disclose
Lillian Gonçalves Campos: Nothing to disclose
Lucas Scotta Cabral: Nothing to disclose
Juliana Ávila Duarte: Nothing to disclose
Keywords: Interventional vascular, Neuroradiology brain, Neuroradiology spine, CT, MR, Diagnostic procedure, Embolisation, Myelography, Cerebrospinal fluid, Fistula
Learning objectives Recognize the main MRI features of CSF-venous fistulas and spontaneous intracranial hypotension (SIH). Apply the Bern Score systematically to stratify the probability of SIH. Demonstrate the role of dynamic digital myelography and CT myelography in detecting fistulas. Identify common diagnostic pitfalls and describe strategies to avoid misinterpretation. Integrate clinical suspicion, imaging findings, and a structured scoring system into a reproducible diagnostic pathway.
Read more Background Spontaneous intracranial hypotension is a condition of CSF volume loss. This fits the Monro-Kellie hypothesis: in a closed system, CSF loss is balanced by an increase in the venous compartment. This process leads to classic brain MRI findings: venous engorgement, pachymeningeal enhancement, pituitary hyperemia, and subdural fluid collections.A paradigm shift has occurred with the Schievink classification. Unlike ventral dural tears (Type 1 leaks) and leaking meningeal diverticula (Type 2 leaks), which usually cause spinal longitudinal extradural fluid on MRI, CSF-venous...
Read more Findings and procedure details The Screening: Brain MRI and The Bern ScoreThe diagnostic pathway starts with a Brain MRI. Radiologists often use the SEEPS acronym: Subdural fluid collections, Enhancement of pachymeninges, Engorgement of venous structures, Pituitary hyperemia, and Sagging of the brain. These signs are helpful, but they are qualitative and vary between cases.To improve accuracy, we use the Bern Score, a semi-quantitative system (range 0–9) that predicts spinal CSF leak. It is based on six MRI criteria (Dobrocky et al., JAMA Neurol. 2019). [fig 2] Calculated...
Read more Conclusion The diagnosis of CSF-venous fistulas represents a paradigm shift in the management of spontaneous intracranial hypotension, moving from a search for fluid collections to a hunt for hyperdynamic venous shunts. Our review demonstrates that while the Bern Score provides a robust initial stratification framework, its application requires nuance: recent evidence suggests that isolated cistern effacement measures may yield false positives in normal individuals, underscoring the need for a holistic assessment.Therefore, integrating high-probability MRI screening with lateral decubitus dynamic myelography is...
Read more References Dobrocky, T., Grunder, L., Breiding, P. S., Branca, M., Limacher, A., Mosimann, P. J., Mordasini, P., Zibold, F., Haeni, L., Jesse, C. M., Fung, C., Raabe, A., Ulrich, C. T., Gralla, J., Beck, J., & Piechowiak, E. I. (2019). Assessing Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension with a Scoring System Based on Brain Magnetic Resonance Imaging Findings. JAMA Neurology, 76(5), 580–587. https://doi.org/10.1001/jamaneurol.2018.4921 Mamlouk, M. D., Shen, P. Y., Sedrak, M. F., & Dillon, W. P. (2021). CT-guided fibrin glue...
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