Harun Ozer

Gadolinium-Enhanced MR Cisternography to Evaluate Dural Leaks in Intracranial Hypotension Syndrome

Background and PURPOSE: We evaluated the use of MR cisternography after intrathecal administration of gadopentetate dimeglumine to detect the presence and localization of CSF leaks in 19 patients diagnosed with spontaneous intracranial hypotension syndrome according to the criteria of International Headache Society. MATERIALS AND METHODS: Lumbar puncture with an injection of 0.5 mL of gadopentetate dimeglumine into the subarachnoid space in the lumbar area was performed. MR images of the cervical, thoracic, and lumbar regions in axial, coronal, and sagittal planes with fat-saturated T1-weighted images were acquired. RESULTS: We observed objective CSF leakage in 17 (89%) of 19 patients. In 14 of these 17 patients, the site of dural tear was demonstrated accurately. In 3 of these 17 patients, the contrast leakage was diffuse, and site of the leak could not be located accurately. No leakage was observed in 2 patients. No complications were detected in any of the patients during the first 24 hours after the procedure or during the 6- to 12-month follow-up. CONCLUSION: The current results demonstrate the relative safety, accuracy, and feasibility of intrathecal gadolinium-enhanced MR cisternography to evaluate dural leaks.

Intrathecal Gadolinium-Enhanced MR Cisternography in the Evaluation of CSF Leakage

BACKROUND AND PURPOSE: Radiologic identification of the location of the CSF leakage is important for proper surgical planning and increases the chance of dural repair. This article describes our experience in analyzing clinically suspected cranial CSF fistulas by using MR imaging combined with the intrathecal administration of a gadolinium-based contrast agent. MATERIALS AND METHODS: A total of 85 consecutive patients with suspected CSF fistulas who presented with persistent or intermittent rhinorrhea or otorrhea lasting for more than 1 month between 2003 and 2007 were included in this study. RESULTS: We observed objective CSF leakage in 64 of 85 patients (75%). The CSF leak was located in the ethmoidal region in 37 patients (58%), in the superior wall of the sphenoid sinus in 8 patients (13%), in the posterior wall of the frontal sinus in 10 patients (15%), in the superior wall of the mastoid air cells in 6 patients (9%), and from the skull base into the infratemporal fossa in 1 patient (2%). Two patients (3%) showed leakage into >1 paranasal sinus. CONCLUSIONS: MR cisternography after the intrathecal administration of gadopentate dimeglumine represents an effective and minimally invasive method for evaluating suspected CSF fistulas along the skull base. It provides multiplanar capabilities without risk of radiation exposure and is an excellent approach to depict the anatomy of CSF spaces and CSF fistulas.

Congenital Imperforate Hymen with Hydrocolpos Diagnosed Using Prenatal MRI

WEB This is a Web exclusive article. mperforate hymen is a rare genital anomaly in which a layer of epithelized connective tissue that forms the hymen has no opening and completely obstructs the vaginal introitus. Hydrocolpos and hydrometrocolpos may occur secondary to this condition. Imperforate hymen usually does not cause symptoms until puberty [1]. This anomaly manifests as an abdominal mass that is detectable during the prenatal period only rarely [2]. We present a case of bilateral hydroureteronephrosis caused by hydrocolpos in a female fetus with an imperforate hymen that was diagnosed using prenatal MRI.

Avoidance of misinterpretation of an FDG positive sacral insufficiency fracture using PET/CT scans in a patient with endometrial cancer: a case report.

Whole-body FDG PET is an important tool for imaging of cancer, including skeletal metastases. However, false-positive results can occur in benign diseases such as insufficiency fractures. We report a case of sacral insufficiency fracture in which increased FDG uptake was detected. Correlative CT images obtained by a combined PET/CT scanner excluded a possible false-positive interpretation by revealing the fracture lines at the site of increased FDG uptake.

Is early bladder activity in radionuclide cisternography an indirect sign of spontaneous intracranial hypotension or sequence of lumbar puncture

Spontaneous intracranial hypotension (SIH) is characterized by severe postural headache and low cerebrospinal fluid (CSF) pressure. Radionuclide cisternography (RC) is of some value in diagnosing CSF leakage causing SIH. However, the sensitivity of RC is too low to demonstrate the site of leakage. In these cases, the early appearance of the radioactivity in the urinary bladder has also been used as an indirect finding in the diagnosis of SIH. The aim of this study was to evaluate the diagnostic reliability of early urinary bladder activity as an indirect sign of SIH. We investigated early bladder activity in 21 patients with suspicion of normal pressure hydrocephalus. Of the 21 subjects, 13 (62%) showed early bladder activity. We demonstrated that early bladder activity is observed in patients without CSF leakage such as normal pressure hydrocephalus. Therefore, this indirect finding of RC is not a reliable finding in diagnosing SIH.

Spontaneous Intracranial Hypotension Syndrome in a Patient With Marfan Syndrome and Autosomal Dominant Polycystic Kidney Disease

Intracranial hypotension is typically manifested by orthostatic headache. The most frequent underlying factor is cerebrospinal fluid leakage. It has been suggested that dural structural weakness in some connective tissue diseases may be responsible for dural tears and diverticula and consequently leakage. We present a case of spontaneous intracranial hypotension associated with Marfan syndrome and autosomal dominant polycystic kidney disease. The patient was treated successfully with epidural autologous blood patch. Dural involvements of these hereditary connective tissue diseases are also discussed.

Cranial subarachnoid hemorrhage as an unusual complication of epidural blood patch

Epidural blood patch (EBP) is an effective procedure for the reatment of spontaneous or iatrogenic dural tears. Reported comlications of EBP include lumbar and neck pain, paresthesia, loss f strength in the legs, temporary bradycardia, dizziness, cranial erve paralysis, and pneumocephalus [1–3]. We report a case of 36-year-old woman who developed a headache, persistent nauea, and vomiting because of subarachnoid hemorrhage (SAH) that ccurred after EBP. We suggest that EBP can result in SAH even if nadvertent puncture is avoided.

Intrathecal gadolinium-enhanced MR-cisternography in spontaneous intracranial hypotension associated with Behcet's syndrome.

We report a 32‐year‐old woman diagnosed with spontaneous intracranial hypotension (SIH) and Behcets Syndrome. Suspicion of SIH was based on cervical MRI findings, and magnetic resonanace (MR)‐cisternography revealed dural leaks bilaterally at lumbar region. MR‐cisternography is a recently performed technique and gaining importance in demonstration of CSF fistula.

Percutaneous transluminal angioplasty in pediatric patients with Takayasu arteritis: comparison of initial and long- term results of interventions on aorta and non-aortic vessels.

Takayasu arteritis (TA) is a chronic inflammatory condition of the aorta and other major vessels that usually results in stenosis, occlusion, dilatation, or the formation of aneurysm. The studies on long-term results of percutaneous transluminal angioplasty (PTA) in pediatric patients with TA are limited (1-3). Furthermore, there is no study that compared PTA results of large and medium vessels. Herein we report 15 pediatric TA cases treated with PTA for stenotic lesions of the aorta, renal arteries, celiac truncus and superior mesenteric artery. The aim of this study is to compare initial and longterm results of PTA in largeand medium-sized vessel. Between August 1992 and January 2007, 15 pediatric TA cases with significant stenosis (≥60% stenosis of vessel diameter) of the aorta and/or non-aortic vessel involvement were treated with PTA. Fifteen cases (9 girls, 6 boys; age range 2.5 months18 years; median age, 12 years) were included. Informed consent was obtained from all parents. Although unilateral access was preferred, in two cases, bilateral femoral artery access was used with kissing balloon technique to reduce trauma to the common femoral artery (Table 1). For PTA procedures of the aorta, while inflating the balloon in aorta, renal arteries were protected by keeping the guide-wire in them (3). In cases with severe stenosis (case 6 and case 12), “graded dilatation” was performed to reduce the risk of rupture (Table 1). It means dilatation by gradually increasing balloon diameter. If residual stenosis was less than 40% during the immediate post-PTA arteriogram, the procedure was considered technically successful. Clinical results were based on symptoms, pulses and blood pressure values and were judged as cured, improved or failed. The procedure was considered clinically successful if the clinical results were rated as cured or improved (3). During follow up period, symptomatic patients with suspicious imaging findings were evaluated with diagnostic angiography whether the presence of recurrence (stenosis rate ≥50%). The paired sample t-test, independent samples t-test and the Pearson’s Chi-square test (Epi Info 2000 CDC, Atlanta, USA) were used for deciding about significance of differences for mean preand post-PTA stenosis, technical success of the procedures, rate and time of recurrences, primary patency rate (continued patency without subsequent intervention) and secondary patency rate (continued patency after any necessary intervention) between two groups. During the initial PTA procedures, 13 of the 15 stenotic aorta segments, and 23 of the 26 stenotic non-aortic vessel segments were successfully dilated (Fig.1, 2). In case 4, poor clinical result was observed due to technically unsuccessful dilatation of both the aorta and renal arteries. Case 1 died as the result of an arrhythmia due to hypertrophic cardiomyopathy within 24 hours of PTA. All the remaining cases were clinically successful (Table 1). The follow-up period was 4-168 months (mean: 53.7±65.88 months). Repeated procedure was performed in 6 recurrent cases (Table 1). Overall, 12 of the 15 stenotic segments of the aorta and all the non-aortic vessels were successfully dilated. Due to the small number of cases, statistical evaluation was not performed for clinical results: however, the outcomes are presented in Table 1. The comparison of PTA results between groups are listed in Table 2.

Contrast agent for intrathecal gadolinium administration.

Contrast Agent for Intrathecal Gadolinium Administration We read with interest the article, “Intrathecal Gadolinium-Enhanced MR Myelography Showing Multiple Dural Leakages in a Patient with Marfan Syndrome,” by Kraemer et al. [1], in the July 2005 issue of AJR. To our knowledge, this article is the first report of intrathecal gadolinium-enhanced MR cisternography performed to show dural tears in a spontaneous intracranial hypotension case. We think that intrathecal gadoliniumenhanced MR myelography will be the diagnostic technique of choice in the future for spontaneous intracranial hypotension. However, we would like to criticize the use of gadobenate dimeglumine (Multihance, Bracco Diagnostics) by the authors for intrathecal gadolinium-enhanced MR cisternography. Studies of safety and tolerance of intrathecal gadolinium administration in both animal and human models were performed by Jinkins et al. [2] using gadopentetate dimeglumine (Magnevist, Schering). Also, in subsequent reports of Tali et al. [3], Reiche et al. [4], and Aydin et al. [5] gadopentetate dimeglumine was used as the gadolinium-containing contrast medium. These studies have led to the integration of data over the use of gadopentetate dimeglumine. However, Kraemer et al. [1] used gadobenate dimeglumine for their case, although the use of that contrast agent has been reported only in a single clinical case and a single animal model in the literature [6]. Although this technique made a major contribution to the diagnosis of CSF leakage in the patient in the case of Kraemer et al. [1], we do not agree with the use of gadobenate dimeglumine instead of gadopentetate dimeglumine, which is well studied for intrathecal administration.