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Reply: REPLY: patients (usually with previous negative findings on lateral decu- bitus DSM), our initial study for CSF leak investigation in hank you for such a thoughtful and timely letter. It certainly patients without extradural spinal fluid remains lateral decubitus Tbrings up important and actively researched points of myelo- DSM. DSM is then followed by the dual-energy CTM with the graphic contrast timing and the preferred study for CSF leak patient in the same lateral decubitus position, usually approxi- detection (particularly, CSF-venous fistulas). mately 15–20 minutes after the DSM. We do agree with Drs Mamlouk and Shen on the importance Given the potential intermittent nature of the CSF-venous fis- of prompt imaging after contrast injection for CSF-venous fistula tulas, in our experience, this as well as other types of CSF leaks localization and further evaluation of sensitivity and specificity are sometimes only or better visualized on the post-DSM dual- for this type of CSF leak detection with lateral decubitus CT my- energy CTM (particularly on 50-keV virtual monoenergetic elography (CTM) versus lateral decubitus digital subtraction my- images), which was the focus of our article. Therefore, while elography (DSM). We would like to clarify, though, that our efforts evaluating the sensitivity and specificity of lateral decubi- article was not investigating these issues, but rather addressing tus DSM versus lateral decubitus CTM for CSF-venous fistula contrast conspicuity at different energy levels and the utility of detection continue, if CT myelography (immediate dynamic or dual-energy CT for CSF leak visualization. delayed as described in our article) is pursued, proceduralists We concur that preferred studies and even techniques for should consider dual-energy CT for optimal extradural contrast CSF-venous fistula localization vary among institutions and are visualization. usually based on institutional and proceduralist preference, com- Thank you again for your letter and the effort to improve fort level, and study familiarity. We also agree with the authors of patient care in this rapidly evolving field. the letter that in patients with a high suspicion of a CSF-venous fistula and negative findings on lateral decubitus DSM or lateral decubitus CTM, it may be beneficial to pursue the other tech- S.J. Huls D.P. Shlapak nique to improve leak detection. At our institution, for example, D.K. Kim while we do perform dynamic lateral decubitus CTMs in select S. Leng C.M. Carr Department of Radiology Mayo Clinic, Ringgold Standard Institution http://dx.doi.org/10.3174/ajnr.A7803 Rochester, Minnesota AJNR Am J Neuroradiol 44:E17 Mar 2023 www.ajnr.org E17 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Neuroradiology American Journal of Neuroradiology

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Publisher
American Journal of Neuroradiology
Copyright
© 2023 by American Journal of Neuroradiology
ISSN
0195-6108
eISSN
1936-959X
DOI
10.3174/ajnr.a7803
Publisher site
See Article on Publisher Site

Abstract

REPLY: patients (usually with previous negative findings on lateral decu- bitus DSM), our initial study for CSF leak investigation in hank you for such a thoughtful and timely letter. It certainly patients without extradural spinal fluid remains lateral decubitus Tbrings up important and actively researched points of myelo- DSM. DSM is then followed by the dual-energy CTM with the graphic contrast timing and the preferred study for CSF leak patient in the same lateral decubitus position, usually approxi- detection (particularly, CSF-venous fistulas). mately 15–20 minutes after the DSM. We do agree with Drs Mamlouk and Shen on the importance Given the potential intermittent nature of the CSF-venous fis- of prompt imaging after contrast injection for CSF-venous fistula tulas, in our experience, this as well as other types of CSF leaks localization and further evaluation of sensitivity and specificity are sometimes only or better visualized on the post-DSM dual- for this type of CSF leak detection with lateral decubitus CT my- energy CTM (particularly on 50-keV virtual monoenergetic elography (CTM) versus lateral decubitus digital subtraction my- images), which was the focus of our article. Therefore, while elography (DSM). We would like to clarify, though, that our efforts evaluating the sensitivity and specificity of lateral decubi- article was not investigating these issues, but rather addressing tus DSM versus lateral decubitus CTM for CSF-venous fistula contrast conspicuity at different energy levels and the utility of detection continue, if CT myelography (immediate dynamic or dual-energy CT for CSF leak visualization. delayed as described in our article) is pursued, proceduralists We concur that preferred studies and even techniques for should consider dual-energy CT for optimal extradural contrast CSF-venous fistula localization vary among institutions and are visualization. usually based on institutional and proceduralist preference, com- Thank you again for your letter and the effort to improve fort level, and study familiarity. We also agree with the authors of patient care in this rapidly evolving field. the letter that in patients with a high suspicion of a CSF-venous fistula and negative findings on lateral decubitus DSM or lateral decubitus CTM, it may be beneficial to pursue the other tech- S.J. Huls D.P. Shlapak nique to improve leak detection. At our institution, for example, D.K. Kim while we do perform dynamic lateral decubitus CTMs in select S. Leng C.M. Carr Department of Radiology Mayo Clinic, Ringgold Standard Institution http://dx.doi.org/10.3174/ajnr.A7803 Rochester, Minnesota AJNR Am J Neuroradiol 44:E17 Mar 2023 www.ajnr.org E17

Journal

American Journal of Neuroradiology – American Journal of Neuroradiology

Published: Mar 1, 2023

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