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Demonstration of Cerebrospinal Fluid Leakage on Radionuclide Cisternography by SPECT/CT Gu¨l Nihal Nursal, MD, and Ali Fuat Yapar, MD Abstract: We report a case of a 37-year-old woman with severe headache provoked by postural changes who was referred to the nuclear medicine department for radionuclide cisternography to demonstrate suspected cerebrospinal fluid leakage. There was an increased uptake laterally on the left paraspinal region of upper thoracal spine and posteriorly on the upper cervical region. Fused SPECT/CT images located the exact leakage site as at the first costovertebral junction level on the left side laterally and on the posterior region of the first and second cervical spine. The treatment with epidural blood patch was successful. Key Words: cerebrospinal fluid leakage, radionuclide cisternography, SPECT/CT (Clin Nucl Med 2015;40: e55Ye57)

Received for publication September 6, 2013; revision accepted December 11, 2013. From the Department of Nuclear Medicine, Adana Teaching and Research Center, Bas¸kent University Faculty of Medicine, Adana, Turkey. Conflicts of interest and sources of funding: none declared. ¨ niversitesi Adana Uygulama ve Aras¸tırma Reprints: Gu¨l Nihal Nursal, MD, Bas¸kent U Merkezi, Dadalo?lu Mahallesi 2591 Sok. No:4/A 01250 Yu¨re?ir Adana, Tu¨rkiye. E-mail: [email protected] Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/15/4001Y0e55

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REFERENCES 1. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295:2286Y2296. 2. Rahman M, Bidari SS, Quisling RG, et al. Spontaneous intracranial hypotension: dilemmas in diagnosis. Neurosurgery. 2011;69:4Y14. 3. Gordon N. Spontaneous intracranial hypotension. Dev Med Child Neurol. 2009;51:932Y935. 4. Hyun SH, Lee KH, Lee SJ, et al. Potential value of radionuclide cisternography in diagnosis and management planning of spontaneous intracranial hypotension. Clin Neurol Neurosurg. 2008;110:657Y661. 5. Chiu YL, Tsay DG, Hu C, et al. Intrathoracic renal ectopia mimicking CSF leakage on radionuclide cisternography demonstrated by SPECT/CT. Clin Nucl Med. 2012;37:93Y94. 6. Thomas DL, Menda Y, Graham MM. Radionuclide cisternography in detecting cerebrospinal fluid leak in spontaneous intracranial hypotension: a series of four case reports. Clin Nucl Med. 2009;34:410Y416. 7. Arai H, Yamamoto Y, Maeda Y, et al. SPET/CT imaging in radionuclide cisternography to detect cerebrospinal fluid leakage in spontaneous intracranial hypotension associated with SLE. Eur J Nucl Med Mol Imaging. 2012; 39:1225Y1226. 8. Morioka T, Aoki T, Tomoda Y, et al. Cerebrospinal fluid leakage in intracranial hypotension syndrome: usefulness of indirect findings in radionuclide cisternography for detection and treatment monitoring. Clin Nucl Med. 2008;33: 181Y185.

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Nursal and Yapar

& Volume 40, Number 1, January 2015

FIGURE 1. A 37-year-old woman was admitted with progressive headache, nausea, vomiting, dizziness, and photophobia for 3 months, which worsened for the last 2 weeks. On MRI, the ventricles were narrow, and the cerebellar tonsils were mildly herniated, which suggested spontaneous intracranial hypotension (SIH). The lumber puncture opening pressure was below reference range and measured as 2 cm H2O. Laboratory analysis of the cerebrospinal fluid (CSF) revealed a positive Brucella agglutination titer. Results of other laboratory parameters of CSF were otherwise within reference range. She was prescribed for radionuclide cisternography to evaluate possible CSF leakage as a reason for SIH. Serial planar images of the spine and the cranium were obtained at 30 minutes, 2 and 6 hours after the intrathecal injection of 3 mCi (111 MBq) 99m Tc-diethylenetriaminepentaacetic acid. All the planar images revealed abnormal radiotracer activity at the paraspinal region of the upper thoracal spine (arrow) and the posterior region of the upper cervical spine (arrowhead).

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CSF Leakage on SPECT/CT

FIGURE 2. SPECT/CT fused images with in axial planes (A) and in saggital plane (B) clearly demonstrate abnormal radiotracer activity at C1 and C2 level posteriorly and at T1 level. To treat the patient, epidural blood patch was applied. After the application of epidural blood patch, the symptoms of the patient decreased dramatically. She also received appropriate antibiotherapy for brucellosis. Spontaneous intracranial hypotension is a rare clinical entity and is caused by spontaneous CSF leakage.1 Orthostatic headache is the most characteristic symptom. Other symptoms include neck stiffness, nausea, vomiting, photophobia, and change in hearing. Although trauma, malignancy, and meningitis are possible causes of CSF leakage, no evident etiology was recorded in our patients’ medical history. Women are more likely than men to receive this diagnosis (2:1), and the peak incidence is at approximately 40 years.2,3 Radionuclide cisternography is of potential value in diagnosing CSF leakage for SIH.4Y7 Although the accumulation of radioactivity in the area outside the subarachnoid space is a direct demonstration of CSF leakage, indirect findings such as early visualization of renal and bladder activity, slow ascent along the spinal axis, and poor propagation of radiotracer to the convexities may also be signs of CSF leakage.8 The mainstay of treatment is the injection of autologous blood into the spinal epidural space, termed as epidural blood patch.1 While performing radionuclide cisternography, the use of SPECT/CT imaging can improve poor spatial resolution of planar images and identify accurate site of CSF leakage.

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We report a case of a 37-year-old woman with severe headache provoked by postural changes who was referred to the nuclear medicine department for radi...
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