mrimaster

Cervical Spine CSF Leak Protocol and Planning

Cerebrospinal Fluid (CSF) Leak

A cerebrospinal fluid (CSF) leak occurs when there is a tear or hole in the dura mater, the outermost layer of the meninges that surrounds the brain and spinal cord, allowing the fluid that cushions these structures to escape. This leakage can result from various causes, including trauma, surgical complications, or spontaneous dural tears. CSF leaks can occur at different levels of the spine or around the skull.

Indications for mri Cervical Spine CSF Leak scan

Contraindications

Patient preparation

Positioning

MRI cervical spine positioning photo

Recommended CSF Leak Protocol and Planning

localiser

A three-plane localizer must be taken at the beginning to localize and plan the sequences. Localizers are normally less than 25 seconds, and they consist of T2\T1 weighted low-resolution scans.

mri C spine CSF leak protocol localiser image image

T2 SPACE 3D sagittal 0.7 mm isotropic with high TE

Plan the sagittal 3D block on the coronal localizer, angling the positioning block parallel to the spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is angled appropriately, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 250mm). The slices should sufficiently cover the spine from the lateral border of the right transverse process to the lateral border of the left transverse process. Place a saturation band over the neck (in front of the esophagus) in the sagittal plane to avoid swallowing and pulsation artifacts over the spinal area. The phase direction should be head to foot to prevent motion artifacts from the neck.

Note: This 3D sequence is acquired with a TE of 250-350ms. This high TE highlights the CSF and suppresses the background, which is beneficial for identifying a CSF leak.

mri Cervical Spine CSF leak protocol sagittal T2 SPACE 3D planning and protocol image

Parameters

TR

1500-2000

TE

250-350

SLICE

0.7 MM

FLIP

120-150

PHASE

H>F

MATRIX

320X320

FOV

250-260

GAP

20%

NEX(AVRAGE)

1.4

3D SPACE sagittal Images

T2 SPACE sagittal 0.7 mm isotropic with high TE CSF leack protocol image
T2 SPACE sagittal 0.7 mm isotropic with high TE CSF leack protocol image 2
3

T2 tse sagittal 3mm

Plan the sagittal slices on the coronal localizer, angling the positioning block parallel to the spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is angled appropriately, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 250mm). The slices should sufficiently cover the spine from the lateral border of the right transverse process to the lateral border of the left transverse process. Place a saturation band over the neck (in front of the esophagus) in the sagittal plane to avoid swallowing and pulsation artifacts over the spinal area. The phase direction should be head to foot to prevent motion artifacts from the neck.

mri C spine CSF leak protocol sagittal T2 planning and protocol image

Parameters

TR

3000-4000

TE

100-120

SLICE

3 MM

FLIP

130-150

PHASE

H>F

MATRIX

320X320

FOV

250-260

GAP

10%

NEX(AVRAGE)

2

STIR sagittal 3mm

Plan the sagittal slices on the coronal localizer, angling the positioning block parallel to the spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is angled appropriately, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 250mm). The slices should sufficiently cover the spine from the lateral border of the right transverse process to the lateral border of the left transverse process. Place a saturation band over the neck (in front of the esophagus) in the sagittal plane to avoid swallowing and pulsation artifacts over the spinal area. The phase direction should be head to foot to prevent motion artifacts from the neck.

mri C spine CSF leak protocol sagittal T2 planning and protocol image

Parameters

TR

7000-9000

TE

110

FLIP

150

NEX

2

SLICE

3 MM

MATRIX

320X256

FOV

250

PHASE

H>F

GAP

10%

TI

150

T1 TSE sagittal 3mm

Plan the sagittal slices on the coronal localizer, angling the positioning block parallel to the spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is angled appropriately, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 250mm). The slices should sufficiently cover the spine from the lateral border of the right transverse process to the lateral border of the left transverse process. Place a saturation band over the neck (in front of the esophagus) in the sagittal plane to avoid swallowing and pulsation artifacts over the spinal area. The phase direction should be head to foot to prevent motion artifacts from the neck.

mri C spine CSF leak protocol sagittal T2 planning and protocol image

Parameters

TR

400-600

TE

15-25

SLICE

3 MM

FLIP

150

PHASE

H>F

MATRIX

320X320

FOV

250-260

GAP

10%

NEX(AVRAGE)

2

T2 SPACE 3D sagittal 0.7 mm isotropic with high TE at the area of interest

Plan the axial 3D block on the sagittal plane at the suspected leak area and angle the positioning block perpendicular to the spinal cord. In the coronal plane, ensure the block is angled appropriately, parallel to the intervertebral disc space. The slices should sufficiently cover the area of interest. If unsure, consult the radiologist or cover the entire cervical spine with 1mm slices. Place a saturation band over the neck (in front of the esophagus) in the sagittal plane to avoid swallowing and vascular pulsation artifacts over the spinal area.

mri Cervical Spine CSF leak protocol axial T2 SPACE 3D planning and protocol image

Parameters

TR

1500-2000

TE

250-350

SLICE

0.7 MM

FLIP

120-150

PHASE

A>P

MATRIX

256X256

FOV

160-180

GAP

20%

NEX(AVRAGE)

1.4

T1 TSE Axial 3mm

Plan the axial slices on the sagittal plane at the suspected leak area and angle the positioning block perpendicular to the spinal cord. In the coronal plane, ensure the block is angled appropriately, parallel to the intervertebral disc space. The slices should sufficiently cover the area of interest. If unsure, consult the radiologist or cover the entire cervical spine with 1mm slices. Place a saturation band over the neck (in front of the esophagus) in the sagittal plane to avoid swallowing and vascular pulsation artifacts over the spinal area.

mri C spine CSF leak protocol axial T2 planning and protocol image

Parameters

TR

400-500

TE

15-20

FLIP

150

NEX

2

SLICE

3 MM

MATRIX

256X256

FOV

150-180

PHASE

A>P

R>L

GAP

10%

oversample

100%

For contrast enhanced CSF Leak imaging

Use T1 TSE fat-saturated axial and sagittal sequences after the administration of IV gadolinium DTPA injection (copy the planning outlined above). The document below provides access to the recommended dosage of gadolinium DTPA injection, as advised by the manufacturer.

Additional sequences for CSF flow study

Cerebrospinal fluid (CSF) flow MRI is an imaging technique used to visualize and measure the flow of cerebrospinal fluid within the brain and spinal cord. This advanced MRI method utilizes phase-contrast imaging to capture dynamic flow patterns and quantify the velocity and volume of CSF movement. It is particularly useful for diagnosing conditions like hydrocephalus, Chiari malformations, and spinal CSF leaks.

CSF flow and VENC settings

Normal CSF flow velocities can vary significantly based on the individual, the location measured, and physiological conditions, but general guidelines include:

  • Peak systolic velocities range from 5 to 10 cm/s in the cerebral aqueduct.
  • VENC settings are often set around 5 to 25 cm/s, depending on the expected velocity of CSF flow in the region of interest.

The ideal method for conducting a CSF flow sequence involves using a VENC scout to identify the optimal flow value. However, radiographers often find it challenging to determine this optimal value. For this reason, we prefer to perform multiple scans with different VENC settings. Since the scan time is very short per sequence, performing multiple VENC scans takes almost the same amount of time as performing the scans with a VENC scout.

Cervical Spine CSF FLOW IN- PLANE SCAN PROTOCOL AND PLANNING

CSF flow in-plane VENC 6cm\sec

Plan the sagittal flow sequence slice on the coronal localizer, angle the positioning block parallel to the mid spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is appropriately angled, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 240mm).

mri spine sagittal CSF Flow protocol and planning for C Spine CSF leak

Parameters

TR

23.7

TE

7.78

FLIP

20

NEX

1

SLICE

6MM

MATRIX

256×205

FOV

180

PHASE

A>P

VELOCITY

 6cm\sec  

TRIGGER

Pulse/Retro

CSF flow in-plane images

CSF Flow Magnitude Image Cervical Spine Image
CSF Flow Magnitude Image Cervical Spine Image
CSF Flow Magnitude Image Cervical Spine Image
CSF Flow Re-phased Image of Cervical Spine5
CSF Flow Re-phased Image of Cervical Spine
CSF Flow Re-phased Image of Cervical Spine
CSF Flow Phase Image - Cervical Spine
CSF Flow Phase Image - Cervical Spine3
CSF Flow Phase Image - Cervical Spine5

CSF flow in-plane VENC 10cm\sec

Plan the sagittal flow sequence slice on the coronal localizer, angle the positioning block parallel to the mid spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is appropriately angled, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 240mm).

mri spine sagittal CSF Flow protocol and planning for C Spine CSF leak

Parameters

TR

23.7

TE

7.78

FLIP

20

NEX

1

SLICE

6MM

MATRIX

256×205

FOV

180

PHASE

A>P

VELOCITY

 10cm\sec  

TRIGGER

Pulse/Retro

CSF flow in-plane VENC 15cm\sec

Plan the sagittal flow sequence slice on the coronal localizer, angle the positioning block parallel to the mid spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is appropriately angled, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 240mm).

mri spine sagittal CSF Flow protocol and planning for C Spine CSF leak

Parameters

TR

23.7

TE

7.78

FLIP

20

NEX

1

SLICE

6MM

MATRIX

256×205

FOV

180

PHASE

A>P

VELOCITY

 15cm\sec  

TRIGGER

Pulse/Retro

CSF flow in-plane VENC 20cm\sec

Plan the sagittal flow sequence slice on the coronal localizer, angle the positioning block parallel to the mid spinal cord. Verify the positioning block in the other two planes. In the axial plane, ensure the block is appropriately angled, parallel to the line running through the center of the vertebral body along the length of the spinous process. Check the positioning block in the sagittal plane to ensure the field of view (FOV) is large enough to cover the entire cervical spine, from the pons down to T2 (typically 240mm).

mri spine sagittal CSF Flow protocol and planning for C Spine CSF leak

Parameters

TR

23.7

TE

7.78

FLIP

20

NEX

1

SLICE

6MM

MATRIX

256×205

FOV

180

PHASE

A>P

VELOCITY

 20cm\sec  

TRIGGER

Pulse/Retro

CSF flow through- plane scan protocol and planning

CSF flowthrough- plane VENC 6cm\sec

Plan the axial CSF flow slice on the sagittal plane at the suspected leak area and angle the positioning block perpendicular to the spinal cord. In the coronal plane, ensure the block is angled appropriately, perpendicular to the spinal cord.

mri spine axial CSF Flow protocol and planning for C Spine CSF leak

Parameters

TR

23.7

TE

7.78

FLIP

20

NEX

1

SLICE

6MM

MATRIX

256×205

FOV

180

PHASE

A>P

VELOCITY

 6cm\sec  

TRIGGER

Pulse/Retro

Repeat the PC flow sequence with VENC 10 cm/sec, 15 cm/sec, and 20 cm/sec