1511. Clinical Outcomes Following Surgical Ligation of CSF Venous Fistula in Patients with Intracranial Hypotension: A Prospective Study

Authors: Timothy Y. Wang, MD; Isaac Karikari, MD; Timothy Amrhein, MD; Linda Gray, MD; Peter Kranz, MD (Durham, NC)

Introduction: Cerebrospinal fluid to venous fistula (CVF) is a newly described etiology for spontaneous intracranial hypotension (SIH). Recently, surgical ligation of CVF has been established as a therapeutic option for patients failing more conservative therapy. The purpose of this study is to determine the clinical outcomes and complication rates following surgical ligation of CVF causing SIH.

Methods: Patients with SIH secondary to a CVF that underwent surgical ligation between 2012 and 2018 were prospectively enrolled. Inclusion criteria included diagnosis of SIH, and demonstration of CVF on CT-myelogram. Demographic factors, CVF location, and description and duration of symptoms were recorded.  The Headache Impact Test (HIT-6) was administered to all patients pre-operatively and then re-administered at least 6 weeks after surgery. Additionally, the Patient Global Impression of Change (PGIC) was also administered at follow-up. Perioperative complications and 30-day readmission rates were recorded. 

Results: 20 patients (16 female) met inclusion criteria for this study. Mean age and BMI were 51.3±13.6 years and 26.0±4.2 kg/m2, respectively. T8-9 (N=5, 25.0%) and T11-12 (N=5, 25.0%) were the most commonly involved levels. Mean baseline HIT-6 score was almost universally high (64.7±6.4, range [44-76]). Postoperatively, the mean follow-up time point was 16.0±9.7 months with a mean postoperative HIT-6 score of 44.1±8.4 (mean change of -20.6±-9.3 points). With respect to the PGIC survey, 18 (90.0%) patients responded most favorably that they were “a great deal better, and a considerable improvement that has made all the difference”, where the remaining two patients responded that treatment resulted in headaches that were “better, and a definite improvement that has made a real and worthwhile difference”. There were no short or long-term perioperative complications and no 30-day readmissions.  

Conclusion: Surgical ligation of CVF for SIH is a safe and efficacious therapeutic option for patients failing more conservative therapy.