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Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening

  • Diagnostic Neuroradiology
  • Published:
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Abstract

Purpose

To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility.

Methods

In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen’s kappa statistics, interobserver agreement was assessed.

Results

In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39).

Conclusion

The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.

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Data availability

The datasets generated during the current study are available from the corresponding author on reasonable request.

Abbreviations

SIH:

Spontaneous intracranial hypotension

CSF:

Cerebrospinal fluid

DPME:

Diffuse pachymeningeal enhancement

DPMH:

Diffuse pachymeningeal hyperintensity

FLAIR:

Fluid-attenuated inversion recovery

T1ce:

Contrast-enhanced T1-weighted imaging

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Funding

The authors did not receive support from any organization for the submitted work.

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Authors and Affiliations

  1. Department of Radiology, Koc University Hospital, Zeytinburnu, 34010, Istanbul, Turkey

    Sabahattin Yuzkan

  2. Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey

    Tahsin Benlice, Tevfik Guzelbey, Mehmed Fatih Yilmaz, Oner Ozbey, Merve Sam Ozdemir, Ozgur Kilickesmez & Burak Kocak

  3. Department of Radiology, Bezmialem Vakif University Hospital, Istanbul, Turkey

    Serdar Balsak

  4. Department of Radiology, Ege University School of Medicine, Izmir, Turkey

    Uluc Ozkiziltan

  5. Department of Neurology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey

    Yavuz Altunkaynak

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  1. Sabahattin Yuzkan
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Contributions

The first draft of the manuscript was written by [Sabahattin Yuzkan]. [Sabahattin Yuzkan] and [Burak Kocak] contributed to the study conception and design. [Sabahattin Yuzkan], [Burak Kocak], [Tahsin Benlice], [Tevfik Guzelbey], [Serdar Balsak], [Mehmed Fatih Yilmaz], [Oner Ozbey], [Merve Sam Ozdemir], [Uluc Ozkiziltan], [Yavuz Altunkaynak], and [Ozgur Kilickesmez] contributed to the material preparation, data collection, and analysis. All authors made substantial contributions to the interpretation of data. All authors critically revised manuscript. All authors approved the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Burak Kocak.

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Conflict of interest

The authors declare no conflict of interest.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the Helsinki declaration and its later amendments or comparable ethical standards.

This study was performed in line with the principles of the Declaration of Helsinki. Institutional review board approval was granted by the medical Ethics Committee (decision no: 534; decision date: 08/11/2023).

This article does not contain any studies with animals performed by any of the authors.

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Written informed consent necessity was waived by the ethics committee as the study had retrospective design and all data were anonymized.

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Yuzkan, S., Benlice, T., Guzelbey, T. et al. Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening. Neuroradiology (2024). https://doi.org/10.1007/s00234-024-03359-2

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