Teaching NeuroImage: Ultrafast Dynamic CT Myelography for the Identification of Leakage Level in Multiple Meningeal Diverticula

A 26-year-old woman presented with symptoms of orthostatic headache for 1 year that temporarily improved after 2 nontargeted epidural blood patches. Despite this intervention, she had persistent radiologic signs of CSF hypotension (Figure 1) and multiple meningeal diverticula on conventional CT myelography (Figure 2, A and C). Ultrafast dynamic CT myelography confirmed only 1 T8-T9 right-side meningeal diverticula in the initial phases (Figure 2, B and D), with later opacification of the remaining diverticula. Surgical treatment resulted in symptom resolution.

Figure 1 Brain MRI

Midline sagittal T1-weighted contrast-enhanced images showing diffuse venous sinus engorgement (stars), pituitary enlargement with effacement of the suprasellar cistern (short arrows), and sagging of posterior fossa structures with reduced mamillopontine distance (long arrows). MRI at first presentation (A) and 1 year later after relapsing symptoms and before surgical treatment (B).

Figure 2
Figure 2 CT Myelography

Coronal conventional CT myelography shows multiple meningeal diverticula (long arrows) and leakage of intrathecal contrast to the epidural spaces (short arrows) (A, C). Ultrafast dynamic myelography shows opacification of only 1 large diverticula at the right side of T8-T9 (B, D) in the initial phases, with later opacification of the remaining diverticula (not shown).

Ultrafast dynamic CT myelography can identify ventral dural tears, leaking meningeal diverticula and CSF-venous fistula, with superior contrast and temporal resolution than MRI. Greater radiation exposure is necessary1,2 and should be balanced against diagnostic precision.

Study Funding

The authors report no targeted funding.


The authors reports no relevant disclosures. Go to Neurology.org/N for full disclosures.

Appendix Authors



  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Submitted and externally peer reviewed. The handling editor was Roy Strowd III, MD, Med, MS.

  • Teaching slides links.lww.com/WNL/C462

  • Received June 3, 2022.
  • Accepted in final form September 15, 2022.

Source link

Back to top button