title: Patterns of cerebrospinal fluid (CSF) distribution in patients with spontaneous intracranial hypotension: Assessed with magnetic resonance myelography.
abstract: BACKGROUND
  Diagnosis of spontaneous intracranial hypotension (SIH) relies on the ability of medical staff to recognize cerebrospinal fluid (CSF) leakage at the spine. However, difficulties with interobserver discrepancy sometimes occurred while reading magnetic resonance myelography (MRM) because clear image definition was lacking. In this study, we tried to determine which pattern of CSF distribution is more reliable for diagnosis of CSF leakage by using MRM.
  
  
  METHODS
  From January 2012 to August 2014, 19 SIH patients and 27 healthy controls (HC) were recruited into our study; 10 of the 19 patients were recovered (SIH-R) after treatment. Whole spine MRM was performed using the 3D-SPACE (three-dimensional sampling perfection with application-optimized contrasts using different flip-angle evolutions) sequence, and interpreted by two experienced neuroradiologists. Two 4-point classification systems of CSF distribution were used to evaluate the three-dimensional maximum intensity projection (3D MIP) and the thin-slice axial multiplanar reconstruction (MPR) images, respectively.
  
  
  RESULTS
  The interobserver agreement between the two readers interpreting the 3D MIP and thin-slice axial MPR MRM were moderate to good (κ=0.60-0.78). Grade 3 of 3D MIP and Type D of axial MPR MRM were only noticed in the SIH. Overall, Grade 3 of MIP and Type D of MPR showed significant difference (p<0.008) between the SIH and the HC in the whole spine. Type C at the T-spine was more frequently noted in the SIH than in the HC (p<0.038). By using "Grade 3", "Type D", "Type D and Type C at T-spine" as the diagnostic criteria of CSF leakage, the sensitivity, specificity, positive predict value (PPV), and negative predict value (NPV) were all > 70%.
  
  
  CONCLUSIONS
  Grade 3 on 3D MIP and Type D on axial MPR MRM were definite criteria of MRM for localizing CSF leakage, and Type C in the T-spine was a probable leakage sign with high sensitivity and NPV.
authors.affiliation: Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
authors.forename: Chuan-Han
authors.initials: CH
authors.lastname: Chen
authors.affiliation: Tu and Yuen Center for Functional Onco-Imaging and Department of Radiological Science, University of California, Irvine, USA; Department of Radiology, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan, ROC.
authors.forename: Jeon-Hor
authors.initials: JH
authors.lastname: Chen
authors.affiliation: Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC. Electronic address: hungchiehchen@gmail.com.
authors.forename: Hung-Chieh
authors.initials: HC
authors.lastname: Chen
authors.affiliation: Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
authors.forename: Jyh-Wen
authors.initials: JW
authors.lastname: Chai
authors.affiliation: Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
authors.forename: Po-Lin
authors.initials: PL
authors.lastname: Chen
authors.affiliation: Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
authors.forename: Clayton Chi-Cheng
authors.initials: CC
authors.lastname: Chen
mesh_terms: D000328:Adult; D065634:Cerebrospinal Fluid Leak / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D019585:Intracranial Hypotension / Q000134:cerebrospinal fluid* / Q000000981:diagnostic imaging; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009192:Myelography; D012189:Retrospective Studies
keywords: cerebrospinal fluid; magnetic resonance myelography; spontaneous intracranial hypotension