A 50 y.o woman was sitting in a chair and had the sudden onset of severe HA.

She was seen at an OSH and LP was negative; MRI showed a CSF leak. What do you see on MRI?

Hint on T2 MRI the csf is bright white

Our patient had a severe headache caused by a spontaneous dural tear. The dura is the outermost layer of the meninges which surround and brain and spinal cord and a hole in this covering allows leakage of CSF. Since the pressure of CSF in the brain is slightly lower than in the spinal cord when standing; fluid will leak out of the tear. This spontaneous intracranial hypotension (SIH) is thought to cause headache because sagging of the intracranial structures occurs stretching sensory nerves. These tears can be associated with calcified intravertebral discs , bone spurs or congenital thin dura. (found in Marfans and Ehlers-Danlos).

While the main symptom of a dural tear is orthostatic headache;  patients can present with other symptoms including:  ringing in the ears, neck pain, or even coma. Since the leak can occur anywhere CSF is present, it is important to localize the site for repair.

The image above is a 14 y.o. golfer with a spontaneous dural tear at T11 as shown by the white area on the T2 weighted MRI.

Spontaneous dural tears are divided into several  types all causing the same orthostatic headache but depending on the location they may be more difficult to image. Other imaging modalities like dynamic MRI (valsalva can increase a slow leak), or CT myelogram  can be used. Treatment options depend on the location and severity of the leak and range from a blood patch, to CSF diversion or even surgery

The ateral dorsal leaks are the easiest to locate

Our patient had a successful  blood patch done by interventional radiology

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 Dobrocky T, Grunder L, Breiding PS, Branca M, Limacher A, Mosimann PJ, et al. Assessing spinal cerebrospinal fluid leaks in spontaneous Intracranial hypotension with a scoring system based on brain magnetic resonance imaging findings. JAMA Neurol. 2019;76:580–587.

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