0:00

So I'm gonna present a case here so you can see the utility of this and,

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and you can hopefully understand what I'm talking about a little bit better.

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And it can reinforce this concept.

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So this is a 32 year old female with postural headaches,

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and this patient has a pretty obvious type one leak.

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So it doesn't require a flow compensated FSS or anything special to see that

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this patient has a fairly decent sized pseudo and Inga seal in the ventral

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epidural space at the thorac lumbar junction Associated with, um, this, uh,

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small disc herniation. Uh, and, um, uh, essentially right below the, the, uh,

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C six, uh, uh, level. So in this case, um,

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the psdo meningeal is big enough that you might not get an accurate localization

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because you're looking at four or five levels.

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So you do need to scan the entire thing, uh,

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and catch the exact moment that the contrast leaks out.

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So this is an example of, uh, of me doing this ultra fast, uh,

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pressure, pressure neutral CT gram. I'm doing basically my, uh, lumbar puncture.

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Uh,

0:55

and I I tend to do it in either the lateral decubitus or prone position and I'll

0:59

put 'em on a bolster and then I'll roll 'em and drop their head and then do the

1:02

smart prep.

1:02

But basically this is the initial immediate CT gram showing this tiny

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little pinpoint dural tear right at the C six level, um,

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just inferior to the C five six disc.

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This shows that same patient in a delayed image,

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you can see the entire psdo meninga seals filled.

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So you can't see that the leak is exactly right here and you're probably

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thinking in your mind what does it matter if if,

1:24

if you localize it exactly here versus over here?

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It matters for the surgeon based on which way they're gonna approach.

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'cause they're gonna approach anteriorly most likely, and they're, in this case,

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they're gonna, uh, approach from the, from the, uh,

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from the right side as opposed to the left. Um, and you can also, um, you can,

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you can also, uh,

1:39

imagine that once you start to look at this in reconstructions,

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it's gonna be a lot harder to see. So I'm gonna demonstrate that, um,

1:46

that this is the mag view of that. You can see this is the,

1:48

the focal area where the leak occurred.

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This is the delayed conventional myelogram where the leak, the, the actual tear,

1:54

the dural rent blends in basically with the entire pseudo meningeal.

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This is the, uh, a level slightly lower around the T one level.

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So you can see the pseudo meninga seal hasn't even filled yet on this ultra fast

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myelogram, whereas on a conventional myelogram, the pseudo meninga seals filled.

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And I just wanna really drive this point home by showing you the,

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the recons of this patient. So when you look at the reconstructions,

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you can see on the conventional myelogram here on the left,

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the entire pseudomeningocele is filled. So you,

2:19

you can't see where the leak is there, there's no way in this blended sort of,

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uh, homogenous, uh, appearing collection in the ventral epidural space,

2:26

you're gonna know exactly where the hole is. Um, but on the ultra fast, um,

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myelogram here on the right where we scan immediately after the injection,

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you can see the pseudo menil is not even filled yet.

2:37

We just have this tiny little pinpoint focus of extravasation and contrast right

2:40

below the C five six disc. And that's exactly where the leak was.

2:43

The surgeon did actually a full corpectomy in this patient and did find the leak

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and did repair it, basically. Um,

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and it was a very focal pinpoint link that they just oversaw and the patient's

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doing well now. So, but that illustrates the, the, the, um,

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the value of localization, um,

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Based upon, uh, those ultra fast CT milligrams.

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And without having the m r I beforehand to actually know where the pseudo

3:05

meningocele was and where to focus, it would be a lot harder for me to detect,

3:08

um, exactly where the leak is because I would miss the exact point of where it's

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leaking. 'cause you can't just scan the entire spine. You have to,

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you have to focus on one area and you have to kind of know ahead of time about

3:18

where the leak is.