Advancements in Detecting Dural Leaks
In superficial siderosis, a common cause of bleeding is a defect or tear in the spinal dura, the protective layer surrounding the spinal cord. These defects often cause slow, hard-to-detect cerebrospinal fluid (CSF) leaks. Finding the source of a leak is critical to stopping further bleeding and limiting damage to the nervous system.
CT myelography is an advanced imaging method that uses contrast dye and CT scanning to visualize the flow of cerebrospinal fluid around the spinal cord. This test is central to identifying spinal leaks in Type 1 superficial siderosis.
Early Work by Dr. Neeraj Kumar at the Mayo Clinic
In 2005, Dr. Neeraj Kumar and his colleagues at the Mayo Clinic highlighted the value of dynamic CT myelography in finding spinal dural defects in patients with SS. This imaging technique was beneficial when traditional tests, like MRI or routine CT, failed to detect the source of the problem. Their work established a foundation for imaging approaches to pinpoint a CSF leak in cases of superficial siderosis.
Advancements by Dr. Wouter I. Schievink
Superficial siderosis (SS) is now classified into two distinct types: Type 1, known as classical infratentorial superficial siderosis, and Type 2, or secondary superficial siderosis. Type 1 is caused by chronic, slow bleeding into the fluid-filled space around the brain and spinal cord. Over time, bleeding deposits iron (hemosiderin) onto the surfaces of the brain, brainstem, and spinal cord, often resulting in symptoms such as hearing loss, balance problems (ataxia), and spinal cord dysfunction (myelopathy). Type 2, on the other hand, is typically triggered by a single bleeding event such as trauma, surgery, or a tumor. In Type 2, any neurological symptoms are generally limited to where the iron settles and does not spread to other areas.
Dr. Wouter I. Schievink of Cedars-Sinai Medical Center has been a leading figure in this field. His work has helped link spinal CSF leaks to conditions like spontaneous intracranial hypotension (SIH) and superficial siderosis. Dr. Schievink strongly advocates using dynamic imaging techniques, especially CT myelography, to find leaks that standard MRI may miss.
He has also developed minimally invasive surgical techniques to repair complex dural tears, especially those in hard-to-reach areas like the thoracic spine. His research continues to stress that finding and repairing the source of the bleeding is the most crucial step in managing Type 1 superficial siderosis and preventing further neurological decline.
The Role of CT Myelography and Advancements in Imaging Technology
Older CT machines often lacked the clarity or speed to capture small or intermittent leaks, unlike today’s CT (MDCT) systems. These new technologies allow real-time imaging that can capture even brief or slow CSF leaks as they happen. The addition of multiplanar reconstruction—viewing images from multiple angles—helps doctors locate the exact point of the leak. These improvements have led to better diagnosis, targeted treatments, and a more precise roadmap for surgeons or radiologists when deciding on repairs. For patients, this means a better chance of slowing down neurological damage.
Emergence of 4D Dynamic CT Myelography: A Breakthrough in Leak Localization
A significant advancement in imaging is the arrival of four-dimensional (4D) dynamic CT myelography. This technique, featured in a 2024 study published in the Journal of Clinical Neuroscience, allows continuous real-time imaging of CSF flow immediately after injecting contrast dye. Unlike older methods that take still images at set intervals, 4D imaging captures CSF leaks in action, even briefly or slowly.
A key finding in the study was the “CSF flow jet,” a visual stream of fluid escaping through a dural tear. Identifying this flow pattern allows physicians to confirm the presence of an active leak with greater confidence. By combining 4D CT with other imaging tools like MRI, doctors can develop a more precise surgery or patching plan, often avoiding unnecessary exploratory work.
This technology is changing how clinicians approach the diagnosis and treatment of SS by making leak detection more accurate and treatment planning more efficient.
Clinical Implications
The ability to find the exact location of a CSF leak has direct benefits for patients. Once the source is found, it can be surgically repaired or sealed with a blood patch. These targeted interventions may not reverse existing nerve damage, but they can help slow or stop further harm caused by ongoing bleeding.
Modern imaging advancements—especially 4D CT myelography—have improved detection and treatment planning for superficial siderosis. Drs. Kumar and Schievink’s clinical work continues to guide how clinicians diagnose and treat this condition, which brings new hope for managing it more effectively for patients and caregivers.
Looking Ahead: A Chance to Meet Dr. Schievink
Building on these foundational contributions, Dr. Wouter I. Schievink will be joining the upcoming Superficial Siderosis Research Alliance (SSRA) Symposium as a featured participant in the Patient Day Q&A panel. This session offers a unique opportunity for patients, caregivers, and healthcare professionals to engage directly with one of the field’s authorities on dural leaks and CT myelography. Attendees will have the chance to ask questions, gain insights into the latest diagnostic approaches, and better understand surgical options for addressing CSF leaks in the context of SS.
References
- Kumar N, Lindell EP, Wilden JA, Davis DH. Role of dynamic CT myelography in identifying the etiology of superficial siderosis. Neurology. 2005;65(3):486-8.
- Schievink WI, Maya MM, Louy C, Moser FG, Tourje J. Intraspinal hemorrhage in spontaneous intracranial hypotension: link to superficial siderosis? AJNR Am J Neuroradiol. 2010;31(5):789-94.
- Hashimoto M, Egawa S, Hirai T, Hashimoto J, Morishita S, Yamada K, Matsukura Y, Kaho R, Hada H, Oyama J, Yoshii T. Detection of Dural Defect Localization Using 4-Dimensional Dynamic Computed Tomography Myelography for Patients with Superficial Siderosis. World Neurosurg. 2024 Jul;187:e798-e806. doi: 10.1016/j.wneu.2024.04.167. Epub 2024 May 3. PMID: 38705268.
Hi,
Are you acquainted with the magazine, Brain Life? Supprted by the American Academy of Neurology. The issues highlight diagnoses, treatment and awareness. They hit the mark in an easily understood/consumer level language. Could this be an appropriate platform to present Superficial Siderosis.? Just a thought….