Dados do Trabalho

Título

Ultrafast dynamic CT myelography for the identification of leakage level in multiple meningeal diverticula

RESUMO

Case Presentation
A 26 year-old woman with clinical and neuroimaging criteria for low cerebrospinal fluid (CSF) pressure headache was submitted to a CT myelography which identified multiple thoracic meningeal diverticula, but specific site of leakage was not possible due to temporal resolution. Ultrafast dynamic CT myelography was then performed and confirmed opacification of only a T8-T9 right-side meningeal diverticula in the initial phases with later opacification of the remaining diverticula and epidural spaces. Targeted surgical treatment with diverticula coagulation and fat grafting with fibrin glue resulted in symptoms resolution.

Discussion
Spontaneous intracranial hypotension (SIH) seems to be related to the structural fragility of the dura mater, which promotes, even if due to minor traumas (eg, coughing and sneezing), a meningeal rupture. Cases that are refractory to clinical treatment may be submitted to a blood patch or surgical intervention. Only 50% of patients with SIH improve after the first blood patch. In refractory cases, the ideal is to identify the exact point of CSF leakage for surgical correction. Myelotomography is highlighted here, as it can identify meningeal diverticula, which correspond to points of fragility. Ultrafast dynamic CT myelography is an option in cases where there is more than one diverticulum and if you want to identify the one responsible for the leak. This technique involved positioning the patient in Trendelenburg and application of intradural contrast while the images were obtained.

Final Comments
Ultrafast dynamic CT myelography is a technique that has been employed mainly in ventral dural ruptures related to osteophytes, but can also be applied in SIH, besides the conventional dynamic myelography.

Palavras Chave

Headache; Spontaneous Intracranial Hypotension; CT Myelography; Meningeal Diverticula