Cerebrospinal fluid venous fistula: Illustrative case

BACKGROUND: Spinal cerebrospinal fluid (CSF) venous fistulas are an under-recognized cause for spontaneous intracranial hypotension (SIH) which may result in postural headaches. CASE DESCRIPTION: A 60-year-old-male presented with 6 years of a persistent headache. The initial brain and spine MRIs and conventional CT myelogram (CTM) showed no CSF venous fistula. However, the lateral decubitus dynamic CTM demonstrated a hyperdense paraspinal vein on the right at the T10-11 level consistent with a CSF venous fistula. It was subsequently successfully treated with surgical ligation. Temporary CSF diversion with lumbar drain was required to treat transient rebound intracranial hypertension. CONCLUSION: The diagnosis of a CSF venous fistulas is often missed on standard brain and spine MRI imaging, and conventional CTM. Dynamic CTM is a more effective modality to detect CSF venous fistulas. Surgical ligation is a safe and effective treatment option. Patients with long-standing SIH may encounter rebound intracranial hypertension after CSF venous fistula ligation and may require temporary CSF diversion.