Embolization of Spinal CSF Dural-Venous Fistulae for Management of Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is characterized by CSF hypovolemia resulting in a variety of symptoms which are dominated by chronic orthostatic headache. SIH is caused by a dural defect leading to a CSF leak or by a CSF dural-venous fistula, a pathologic connection between the CSF-containing spinal nerve root sleeve and an adjacent radicular vein. The purpose of this study was to report outcomes after transvenous embolization of spinal CSF dural-venous fistulae for management of SIH.

Materials and Methods:

Over a 3-year period (August 2021 to May 2024), 192 transvenous embolizations of dural venous fistulae were performed in 139 patients with symptoms of SIH and imaging evidence of dural-venous fistula(e) on CT myelography. Using a common femoral vein approach, a balloon occlusion microcatheter was advanced into the target segmental vein and inflated to allow retrograde injection of Onyx-18 into the associated radicular vein until there was filling of the epidural veins. Medical records were retrospectively reviewed.

Results:

All patients had undergone 1-15 prior blood patch procedures but with symptom recurrence.  All patients had persistent brain MRI findings characteristic of SIH including brain sagging and/or pachymeningeal enhancement. 95% of treated fistulas were located in the thoracic spine. Technical success was achieved in 99% of cases. Complete resolution of symptoms was achieved in 56%. Major improvement in symptoms was achieved in 21.5%. Minor improvement was achieved in 12.5%. No improvement was experienced in 10%. Post-procedure, 89% of patients had some degree of rebound intracranial hypertension symptoms. 48% of had moderate to severe rebound intracranial hypertension warranting acetazolamide. Follow up brain MRI’s showed decrease in signs of intracranial hypotension in 84%. There were no major procedural complications.

Conclusion:

Balloon-occluded retrograde transvenous embolization of spinal CSF dural-venous fistulae demonstrated substantial clinical improvement in the majority of patients with an excellent safety profile. Additional studies are needed to assess durability of clinical response and to further define patient selection criteria.