Safety and efficacy of transvenous embolization of cerebrospinal fluid-venous fistula in patients with spontaneous intracranial hypotension

Background: Transvenous embolization is a recent treatment strategy for cerebrospinal fluid-venous fistulas (CSFVF), which are associated with spontaneous intracranial hypotension (SIH). Methods: Participants were selected from a prospective database on patients with CSFVF that received transvenous Onyx embolization. All patients underwent a brain magnetic resonance imaging (MRI) before and after embolization with MRI follow-up performed at least 3 months after treatment. Clinical and MRI results after treatment were described. Results: Twenty-one consecutive patients (median age 63 years, IQR = 58-71; females: 15/21 = 71.5%) with 30 CSFVF were included. Most lesions were situated between T9 and L1 (19/30 = 63%), 70% were right-sided, and 38% of the patients had multiples fistulas. Embolization was successful in all cases. The mean MRI SIH score before and after treatment was 6 (+/- 2.5) and 1.4 (+/- 1.6), respectively (p < 0.0001). Twenty patients (90%) experienced improvement of their initial condition, of which 67% reported complete clinical recovery. The mean HIT-6 score decreased from 67 (+/- 15) to 38 (+/- 9) (p < 0.0001), the mean amount of monthly headache days from 23.5 (+/- 10) and 3.2 (+/- 6.6) (p < 0.0001), the visual assessment scale (VAS) for headache severity from 8 (+/- 1.9) to 1.2 (+/- 2) (p < 0.0001), and the mean VAS for perception quality of life improved from 2.6 (+/- 2.5) to 8.6 (+/- 1.8) (p < 0.0001). There were no major complications. The suspected rebound headache rate after treatment was 33%. Conclusion: Transvenous embolization of CSFVF allowed high rates of clinical improvement with no morbidity related to the treatment.