A 70-year-old woman had double vision, nausea, neck pain, and acute bilateral hypacusis. The neurological examination showed nerve VI palsy on the right. There was no history of trauma. Brain magnetic resonance (MR) imaging was indicative of intracranial hypotension, with diffuse pachymeningeal thickening, strong dural enhancement, and frontoparietal subdural hygromas. A radioisotope cisternography, performed in the search for a potential spinal cerebrospinal fluid (CSF) leak, was inconclusive. Thus, intrathecal gadolinium-enhanced MR myelography was considered as a possible alternative. Before intrathecal gadolinium administration, an MR image of the spinal cord showed a small perineural cyst at the level of L2 on the right but no evidence of a CSF leakage. The intrathecal gadolinium-enhanced MR myelography provided clear-cut evidence of dural leaks along the right L2 and L3 nerve roots (Figure). According to these findings, targeted epidural blood patching was performed and the patient’s symptoms gradually improved during the following month. At 1-year follow-up, she was asymptomatic.
Papadopoulou A, Ahlhelm F, Ulmer S, Kappos L, Sprenger T. Detection of Cerebrospinal Fluid Leaks by Intrathecal Contrast-Enhanced Magnetic Resonance Myelography. JAMA Neurol. 2013;70(12):1576-1577. doi:10.1001/jamaneurol.2013.744