Jeremy K. Cutsforth-Gregory, M.D., a neurologist at Mayo Clinic in Rochester, Minnesota, explains recent advances in the diagnosis and treatment of cerebral spinal fluid (CSF)-venous fistulas. He also discusses lateral decubitus digital subtraction myelogram, the novel approach for treatment identified at Mayo Clinic. My name is Jeremy cuts. 4th Gregory. I'm a neurologist at Mayo Clinic in Rochester Minnesota and director of our multidisciplinary CSF dynamics Clinic. I'd like to share with you a few recent advances in the diagnosis and treatment of CSF munis fistulas. Officials are one of three recognized types of spontaneous spinal CSF leaks. These abnormal connections between the fecal sack and adjacent veins typically arise from large men and Jill nerve roots leave diverticular in the thoracic region. And mayo clinic would grow up to algorithm for finding suspected leaks and pistol is that starts with MRI of the head, then MRI of the spine to separate patients into those who have a spinal longitudinal, extra dural CSF collection from those who don't. The presence of that CSF indicates a fast leak but its absence indicates a slow leak or topic of today's talk fistula, in which case we do a lateral to cuba, this digital subtraction. My hologram, we've published on the lateral to cuBA's dsm and how to do it. Because we certainly love for other people to adopt this technique. We put patients in the lateral to CUBA's position in order to maximize exposure of the nervous lived in particular and the paris final veins to the contrast. Use the tilting table in order to control the flow rate up the spine. In order to get the necessary resolution. We have to split the spine into two runs basically from mid blue marta mid thoracic and then mid thoracic to mid cervical. That maximizes the amount of contrast the patient get one day so they come back the next stage, do the other side. While we initially did these studies under general anesthesia, we pretty quickly learned that we could get essentially the same quality of images with patients awake, which is mild, moderate sedation. Of course that eliminated the anesthesia exposure made it a lot easier fraud everyone involved Here's an example of a patient who underwent lateral to CUBA'S DSM. This gentleman had an MRI head showing severe brain sag and neural enhancement and on his MRI spine there was not extra dural CSF but there were multiple men and Children enslaved in particular. You can see in the original and subtracted images the bottom panel that there's a clear dense para spinal vein extending off the lateral nerve roots leave. While these lesions have only been recognized since 2014, treatment quickly became ligation of the nerve root, the sleeve and all the associated vascular complex. It's an effective treatment but of course it's invasive. The other limitation of this is that we cannot sacrifice an appendix to root, a cervical root or lumbar route because of course the patient would develop limb weakness. So we've been discussing for some time on how to devise a noninvasive and unlimited treatment approach and I'll end with a case that shows that This 44 year old man had daily headaches that were worse when he was upright and works without salva maneuvers, normal exam. You can see on MRI that he had brain sag, vacuum energy enhancement and on the dsm had this slight flicker of a vein coming off the right th nerve root. One of our endovascular radiologists. Dr wally Brunswick really gets the credit for asking the key question. Said if the problem of a CSF venous fistula is half vein, what if I could navigate to that vein through the vessels and glue it shot from inside? We have previously been focusing on treating the problem of course, from the spinal fluid side of the issue. That's exactly what he did in our novel treatment. The trans venus, para spinal being embolization. Here's what you can see is dr Benedict performing catheterization of pure Vienna Kaveh to find the Oscars vein. Then performing in as a guest venogram to find the paris final veins and finally performing selective catheterization of the target paris mild pain. In this case the right th vein he then glues it shot with olympic liquid symbolic material. The figure shows anatomically what's happening basically obliteration of the paris final thing and all of its tributaries around the fecal sack. That symbolic material shows up on a cT scan which reformed post procedure just to confirm that we did not get into a philosophical extension and that we have a good solid cast so far. We've been using the onyx lip symbolic system and has worked well. Here's that gentleman's fistula in his pre treatment. MRI showing brain zag vacuum energy on hands after embolization. His brains loads up vacuum energy enhancement resolves and he's gone from an invasive spine surgery and all the attendant risks to a two hour outpatient procedure. He was completely headache free within a day. Thank you very much. I hope to be a collaborative partner for you and your patients in whom you suspect a spinal CSF leak or fistula. Yeah.