PT  - JOURNAL ARTICLE
AU  - Huynh, Thien J.
AU  - Parizadeh, Donna
AU  - Ahmed, Ahmed K.
AU  - Gandia, Christopher T.
AU  - Davison, Hal C.
AU  - Murray, John V.
AU  - Mark, Ian T.
AU  - Madhavan, Ajay A.
AU  - Shlapak, Darya
AU  - Rozen, Todd D.
AU  - Brinjikji, Waleed
AU  - Vibhute, Prasanna
AU  - Gupta, Vivek
AU  - Brewer, Kacie
AU  - Fermo, Olga
TI  - Lateral Decubitus Dynamic CT Myelography with Real-Time Bolus Tracking (dCTM-BT) for Evaluation of CSF-Venous Fistulas: Diagnostic Yield Stratified by Brain Imaging Findings
AID  - 10.3174/ajnr.A8082
DP  - 2023 Dec 28
TA  - American Journal of Neuroradiology
4099  - http://www.ajnr.org/content/early/2023/12/28/ajnr.A8082.short
4100  - http://www.ajnr.org/content/early/2023/12/28/ajnr.A8082.full
AB  - BACKGROUND AND PURPOSE: CSF-venous fistulas (CVFs) associated with spontaneous intracranial hypotension (SIH) may have a transient appearance, relative to contrast arrival, which may influence the diagnostic performance of lateral decubitus CT myelography (CTM). We developed a dynamic CTM protocol using real-time bolus-tracking (dCTM-BT) to improve the temporal resolution and standardize the timing of CTM acquisitions post-intrathecal contrast administration. The purpose of our study was to evaluate the feasibility of the dCTM-BT technique and evaluate its diagnostic yield for CVF detection, stratified by brain MRI SIH findings.MATERIALS AND METHODS: Patients with suspected SIH without extradural fluid collection on spine MRI who underwent dCTM-BT were retrospectively reviewed. CT bolus monitoring was performed at the upper thoracic level. Following the visualization of dense intrathecal contrast, at least 3 CTM acquisitions of the spine were obtained and reviewed by 2 neuroradiologists. The Bern SIH score was calculated on the brain MRI. The diagnostic yield for CVF detection was evaluated, stratified by Bern score categories and a receiver operating characteristic (ROC) analysis.RESULTS: Out of 48 patients, 23 (48%) had a CVF on dCTM-BT, located at T1–5 (n = 4), T6–12 (n = 18), L1 (n = 1), with 70% on the right. CVF was identified in 22/22 (100%) of patients who had a high Bern score, 1/7 (14%) of those who had an intermediate score, and 0/19 (0%) of those who had a low score. The area under the ROC curve was 0.99 (95% CI, 0.98–1.00). The optimal cutoff was a Bern score of ≥5 (96% sensitivity, 100% specificity).CONCLUSIONS: dCTM-BT is feasible and has excellent diagnostic performance for CVF identification/localization. The Bern score is strongly associated with CVF detection and may help inform who will benefit from dCTM-BT.CTMCT myelographyCVFCSF-venous fistuladCTM-BTdynamic CT myelogram with bolus-trackingDSMdigital subtraction myelogramIQRinterquartile rangeROCreceiver operating characteristicSDstandard deviationSIHspontaneous intracranial hypotensionSLECspinal longitudinal extradural CSF collection