MRI myelography for diagnosis and targeted blood patching of multilevel thoracic spine CSF leaks: Report of 2 cases

In patients with occult cerebrospinal fluid (CSF) leaks or CSF leak syndrome, orthostatic headaches are a common presenting symptom. Although computed tomography (CT) myelography has historically been the gold standard for diagnosis with radioisotope cisternography as a diagnostic alternative, magnetic resonance imaging (MRI) myelography using intrathecal gadolinium has reported sensitivity of 80%-87%. Two patients with spontaneous orthostatic headaches lasting for several days were diagnosed with CSF leaks at multiple thoracic segments using MRI myelogram with intrathecal gadolinium (Gadavist, Bayer, Whippany, NJ). This allowed for subsequent targeted treatment with CT fluoroscopy guidance, resulting in therapeutic responses within 1-2 treatment with targeted blood patching. Although intrathecal gadolinium is an off-label use, the superior contrast resolution and lack of radiation exposure makes MRI myelography an excellent imaging modality for diagnosing CSF leak, targeting treatment, and monitoring outcomes compared to CT myelography and radioisotope cisternography.