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Research ArticleSPINE

Resisted Inspiration Improves Visualization of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension

P.G. Kranz, M.D. Malinzak, L. Gray, J. Willhite and T.J. Amrhein
American Journal of Neuroradiology July 2023, DOI: https://doi.org/10.3174/ajnr.A7927
P.G. Kranz
aFrom the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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M.D. Malinzak
aFrom the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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L. Gray
aFrom the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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J. Willhite
aFrom the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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T.J. Amrhein
aFrom the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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  • FIG 1.
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    FIG 1.

    A right T12 CVF best visualized during resisted inspiration. Coronal MIP images from CTM performed in a patient with SIH are shown during maximum suspended inspiration (A), resisted inspiration (B), and the Valsalva maneuver (C). Although the CVF (arrow) is visible to varying degrees on all phases, visualization is best during resisted inspiration.

  • FIG 2.
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    FIG 2.

    A right T9 CVF best visualized during resisted inspiration. Axial MIP images from CTM performed on a patient with SIH are shown during maximum suspended inspiration (A), resisted inspiration (B), and the Valsalva maneuver (C). Drainage of the CVF into a segmental vein (arrow) is best seen during resisted inspiration.

  • FIG 3.
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    FIG 3.

    A left T3 CVF best visualized during the Valsalva maneuver. Axial MIP images from CTM performed on a patient with SIH are shown during maximum suspended inspiration (A), resisted inspiration (B), and the Valsalva maneuver (C). The CVF originating at the T3 level on the left (arrow) is best visualized during the Valsalva maneuver. The presence of a CVF was suspected on the basis of faint hyperdensity in the same location on the initial maximum suspended inspiration image.

  • FIG 4.
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    FIG 4.

    A left T7 CVF drainage pattern shifts with varying respiratory phases. Axial images from CTM performed on a patient with SIH are shown during maximum suspended inspiration (A), resisted inspiration (B), and the Valsalva maneuver (C). The primary drainage of the CVF is into the internal epidural venous plexus, but during inspiratory phases, a component of drainage is also seen into the basivertebral venous plexus (black arrows). This drainage decreases during the Valsalva maneuver, with new drainage visible into the external epidural venous plexus via an intervertebral vein (white arrow).

Tables

  • Figures
  • Patient characteristics, CVF location, and behavior of CVF drainage investigated with 3-phase respiratory technique

    Case No.Age (yr)SexCVF LevelCVF SideVisibility PatternaDrainage Pattern Varies with PhasebBest Phase for CVF Visualization
    155FT12RANRI
    249FT3LANMI
    367MT3LANV
    460FL1RANRI
    548FT9RANRI
    657MT5LAYRI
    773MT7LCY–
    844FT7LANRI
    • Note:—The en dash indicates that no single phase was superior; RI, resisted inspiration; MI, maximum suspended inspiration; V, Valsalva maneuver; M, male; F, female; R, right; L, left; N, no; Y, yes.

    • ↵a The visibility pattern is classified as follows: One respiratory phase is superior to the others (A), 2 phases are equally superior to the third (B), or all respiratory phases are equivalent in depicting the CVF (C).

    • ↵b Y indicates that the drainage pattern shifted to other portions of the epidural venous plexus with different respiratory phases; N indicates no shift.

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Cite this article
P.G. Kranz, M.D. Malinzak, L. Gray, J. Willhite, T.J. Amrhein
Resisted Inspiration Improves Visualization of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension
American Journal of Neuroradiology Jul 2023, DOI: 10.3174/ajnr.A7927

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Resisted Inspiration Improves Visualization of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension
P.G. Kranz, M.D. Malinzak, L. Gray, J. Willhite, T.J. Amrhein
American Journal of Neuroradiology Jul 2023, DOI: 10.3174/ajnr.A7927
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