title: C1-C2 cryptic cerebrospinal fluid leak directly identified by pressurized radionuclide cisternography: Case report and review of the literature.
abstract: BACKGROUND
  Patients with chronic postural headaches may suffer from spontaneous intracranial hypotension (SIH). Trauma, degenerative disc spurring and connective tissue disorders are documented risk factors; in most cases there is no inciting event. Despite sophisticated means of evaluating the neuraxis, many cerebrospinal fluid (CSF) leaks are radiographically occult and treatment is focused on thoracic and cervical-thoracic regions. Although lumbar epidural blood patch (EBP) is the initial treatment of choice after failed conservative management, several studies document the need for treatment aimed at the specific leak area.
  
  
  METHODS
  This report describes the case of a 42-year-old female with scleroderma and sudden onset postural headaches. Magnetic resonance imaging revealed diffuse pachymeningeal enhancement suggestive of intracranial hypotension. Computed tomographic myelography demonstrated a collection of fluid ventral to the cervical thecal sac; an exact location for CSF egress was not identified. Conservative measures followed by lumbar EBP failed to alleviate her symptoms. The patient underwent placement of a lumbar drain and dynamic radionuclide cisternography (RIC). Panoramic images of the spine were taken at the time of the pressurized saline injection. The CSF leak was clearly visualized at C1-2. Treatment was focused at this region using percutaneous injection of autologous blood and fibrin glue.
  
  
  CONCLUSIONS
  SIH is disabling if left untreated. Spinal CSF leaks are often discrete and difficult to identify using static imaging. The use of pressurized, RIC by lumbar drain injection allows for the real-time evaluation of CSF dynamics and can more precisely identify slow flow leaks often missed with static imaging.
authors.affiliation: Department of Surgery, Section of Neurosurgery, Providence Hospital and Medical Centers, Michigan State University, East Lansing, United States of America.
authors.forename: Stephanie Reed
authors.initials: SR
authors.lastname: Falatko
authors.affiliation: Department of Surgery, Section of Neurosurgery, Providence Hospital and Medical Centers, Michigan State University, East Lansing, United States of America.
authors.forename: Prashant
authors.initials: P
authors.lastname: Kelkar
authors.affiliation: Department of Surgery, Section of Neurosurgery, Providence Hospital and Medical Centers, Michigan State University, East Lansing, United States of America.
authors.forename: Pradeep
authors.initials: P
authors.lastname: Setty
authors.affiliation: Department of Neurosurgery, Michigan Spine and Brain Surgeons PLLC, Providence Hospital and Medical Centers, MI 48075, United States of America.
authors.forename: Doris
authors.initials: D
authors.lastname: Tong
authors.affiliation: Department of Surgery, Section of Neurosurgery, Providence Hospital and Medical Centers, Michigan State University, East Lansing, United States of America ; Department of Neurosurgery, Michigan Spine and Brain Surgeons PLLC, Providence Hospital and Medical Centers, MI 48075, United States of America.
authors.forename: Teck Mun
authors.initials: TM
authors.lastname: Soo
keywords: Epidural blood patch; percutaneous; radionuclide cisternography; spontaneous cerebrospinal fluid leak; spontaneous intracranial hypotension