Under Pressure: Advancing the Diagnosis of Pediatric CSF Leaks with Digital Subtraction Myelography

BACKGROUND AND PURPOSE: Intracranial hypotension-arising from CSF leaks that are iatrogenic, traumatic, or spontaneous-is a potentially debilitating condition resulting in orthostatic headaches and other neurologic symptoms. While pediatric CSF leaks are challenging to manage due to limited data, digital subtraction myelography (DSM) has shown promise as a highly sensitive diagnostic tool for visualizing these leaks. This study reviews the use of DSM in pediatric patients for diagnosing and localizing CSF leaks at a quaternary center for intracranial hypotension. MATERIALS AND METHODS: Using prospective registries, we analyzed pediatric patients (19 years of age or younger) evaluated for CSF leaks at our institution between 2001 and 2025. Patients underwent DSM under standardized protocols, including adjustments for positioning based on suspected leak locations. Data on demographics, clinical presentation, imaging findings, and outcomes were also analyzed. RESULTS: Forty-one patients (27 females, 14 males; mean age, 15.69 [SD, 3.12] years) underwent 73 DSMs. The average fluoroscopy time was 1.8 (SD 1.4) minutes, and the mean kinetic energy released per unit mass (air kerma) radiation dose was 324.8 (SD, 373.8) mGy. No complications were reported. Among 28 patients with suspected spontaneous intracranial hypotension (SIH), 54 DSMs were performed; orthostatic headache was the presenting symptom in 96.4%. Eighteen leaks were identified in 16 patients (57.1%), most commonly type 1b (33.3%) and type 3 (27.8%) leaks. Of 15 patients undergoing surgery, intraoperative findings confirmed DSM results in 14 cases. Thirteen patients with traumatic or iatrogenic leaks underwent 19 DSMs; orthostatic headache was present in 92.3%. Eight leaks were identified in 6 patients (46.2%), predominantly ventral, and all underwent directed interventions. CONCLUSIONS: DSM is a safe and effective diagnostic technique for pediatric CSF leaks, enabling precise localization critical for targeted treatment. Incorporating DSM into the diagnostic workflow may improve outcomes for children with intracranial hypotension, but further multicenter studies are needed to validate findings and optimize protocols.