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Original research
Clinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization
  1. Waleed Brinjikji1,2,
  2. Ajay Madhavan1,
  3. Ivan Garza3,
  4. Mark Whealy3,
  5. Narayan Kissoon3,
  6. Ian Mark1,
  7. Pearse P Morris1,
  8. Jared Verdoorn1,
  9. John C Benson1,
  10. John L D Atkinson2,
  11. Hassan Kobeissi1,
  12. Jeremy K Cutsforth-Gregory3
  1. 1Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
  3. 3Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Waleed Brinjikji, Department of Radiology, Mayo Clinic, Rochester, Minnesota 55001, USA; Brinjikji.Waleed{at}


Background Cerebrospinal fluid-venous fistulas (CSFVF) are a common cause of spontaneous intracranial hypotension (SIH). Transvenous embolization has emerged as a reliable treatment option. We review the clinical presentation, imaging, and clinical outcomes of 100 consecutive CSFVF patients who underwent embolization over 2 years.

Methods Baseline clinical characteristics, imaging findings (including Bern SIH score), technical outcomes, and long-term imaging and clinical outcomes were collected. All patients had at least 3 months of clinical follow-up and had baseline MRI. 99/100 patients underwent follow-up imaging at ≥3 months post-treatment.

Results 100 patients were included. Mean imaging and clinical follow-up duration was 8.3±7.7 months and 15.0±6.8 months, respectively. The mean duration of symptoms before embolization was 40.9±52 months. Mean baseline Bern SIH score was 5.9±3.3. The most common baseline symptoms were headache (96 patients), tinnitus (55 patients), and cognitive dysfunction (44 patients). Technical success rate was 100%. Mean post-treatment Bern SIH score was 0.9±1.6 (P<0.0001). Following treatment, 95% of patients reported significant improvement or resolution in symptoms (58 patients reporting resolution and 37 reporting improvement). 5 patients reported no improvement. There were no major procedural or periprocedural complications. 10 patients had minor procedural complications that did not result in any change in management (Onyx emboli, venous perforation). 19 patients had rebound intracranial hypertension requiring acetazolamide therapy. 7 patients had recurrent fistula at the initially treated level.

Conclusions Transvenous embolization of CSFVF in SIH patients is safe and effective with a 95% treatment response, significant improvement in imaging outcomes, and a very low rate of complications.

  • Brain
  • Fistula
  • Spine
  • Liquid Embolic Material
  • Vein

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • X @JCGneuro

  • Correction notice Since this article first published, the middle initial C has been added to the author John Benson.

  • Contributors All authors contributed to the drafting and critical revision of the work. WB, HK, and JKC-G were responsible for the final approval of the version to be published. WB is responsible as the overall guarantor of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests WB holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. The remaining authors declare no conflicts of interest.

  • Provenance and peer review Not commissioned; externally peer reviewed.