0:00

This is a patient who had previously undergone a, um, uh, fat sat,

0:05

uh, T two M R I and it showed basically, uh,

0:09

extensive stranding within the epi within the epidural space in a small ventral

0:13

epidural collection, which we can see here in the lumbar spine.

0:16

This happened after an LP at an outside hospital. And,

0:21

um, essentially we weren't sure where the leak was.

0:24

I think the natural presumption is that it's at the clinical level where the

0:28

lumbar puncture was performed,

0:29

but she had numerous blood patches at L four five and it just did not resolve.

0:33

She continued to have severe postural headaches. Um,

0:36

and ultimately we did do a digital subtraction monogram with her in the prone

0:41

position. And here's the injection.

0:42

You can see basically here's your initial injection.

0:44

You're just filling the fecal tract. Um, just so you guys are aware,

0:47

this is the S one level, L five, L four, L three, and then this is L two.

0:51

And then we see a little bit of contrast extravasation at L two three, uh,

0:55

on the initial, uh, or, or the second image here. And then on the third image,

0:59

we can see it clearly flowing backwards into the pseudomeningocele.

1:02

So the puncture clearly occurred much higher than you would suspect based on

1:06

where it should be clinically.

1:07

So it should have been clinically where I put the needle at L four five,

1:10

but it was actually closer to L two three and this was born out in surgery.

1:13

This patient had undergone so many blood patches,

1:16

she just skipped straight to surgery. Dr. I think Dr.

1:18

Shain did the surgery on this patient. And, um, ultimately the,

1:21

the leak was right at two three,

1:22

right where we localized it on the digital subtraction myelogram.

1:25

And he repaired it without any, uh,

1:26

issues and she did well and has had no issues since. Um,

1:30

here's another patient with a type one leak. Sometimes they do present this way.

1:34

This a 74 year old guy with hemorrhagic bilateral subdural collections.

1:37

And the presumption is that this is obviously, uh, gonna be a, uh,

1:41

a subdural hematoma. But this patient had no real, um,

1:46

symptoms referable to the subdural. A patient didn't have any focal deficits.

1:49

He did report a several year history of tinnitus and strange postural

1:54

headaches, and he was a very high performance tennis player,

1:57

despite being 74 and a lot of twisting, bending when you, when you play tennis.

2:01

And he had a lot of degenerative changes in his spine.

2:04

So our spider senses were tingling with this larger collections.

2:07

And you can see he had the couple of discs here in his cervical spine.

2:10

So the presumption is gonna be that the leak must be up here, right?

2:13

It has to be, it can't be anywhere else.

2:16

This is just a standard TT weighted sagittal M r i.

2:18

But this is gonna show you the value of a flow compensated fiesta.

2:21

So the flow compensated fiesta showed actually that the epidural collection was

2:24

down here behind the T one, uh, vertebral body.

2:27

And this helped us really focus when we did the digital subtraction. Gram,

2:30

as I had alluded to earlier, when you get around the cervical thoracic junction,

2:33

it gets a little bit dicey with digital subtraction. But this is the T one,

2:37

T two vertebral bodies that I had marked, um, here. And it basically,

2:39

the leak did occur right where we predicted it, it was going to occur.

2:42

So we have a split in the dura here on the digital subtraction gram,

2:45

exactly where we saw the, uh,

2:47

the small epidural collection on the flow compensated Fiesta m r i.

2:51

Ultimately, I did again, do a blood patch on this patient and he did really,

2:55

really well. The subdurals completely resolved, um, within just a few weeks. So,

2:59

um, presumably we were correct, uh, in, in all of these assumptions, um,

3:02

based upon the M R I. So the m MRI was, uh, you know, uh,

3:05

obviously extremely helpful in this case.