(2026) Schwartz | Streamlined PCCT myelography protocol for detection of CSF-venous fistulas

Daniel Stromer

A streamlined PCCT myelography protocol enabled whole-spine evaluation at 0.2 × 0.1 mm resolution while limiting scanner time to approximately 15 minutes, making high-resolution CSF leak imaging feasible in a busy clinical setting.

In 35 patients with previously inconclusive spine imaging, PCCT definitively identified a CSF leak in 34% (12/35) and suggested a potential leak site in another 23% (8/35). Resistive inspiration was most frequently judged the best breathing phase for leak detection.

PCCT findings enabled more targeted management after extensive prior workup; among treated patients, 62% (18/29) achieved symptom relief following surgery, embolization, or blood/fibrin glue patching.

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Exam protocol

• Intrathecal contrast was administered under fluoroscopic guidance, followed by transport to the PCCT scanner with the patient maintained in a decubitus position.
• The entire spine was imaged with UHR PCCT at 0.2 × 0.1 mm spatial resolution using three breathing phases: resistive inspiration, end inspiration, and Valsalva, resulting in six series per examination.
• In all but two patients, imaging was performed on two consecutive days, once in each decubitus position, allowing side-dependent assessment for CSF-venous fistulas while keeping each scanner session to about 15 minutes.

Source: Schwartz FR, Huang RY, DeSalvo MN, et al. AJNR Am J Neuroradiol. 2026;47(6):1737–1742.