Clinical Outcomes Following Surgical Ligation of Cerebrospinal Fluid-Venous Fistula in Patients With Spontaneous Intracranial Hypotension: A Prospective Case Series

BACKGROUND: Cerebrospinal fluid-venous fistula (CVF) is a recently described cause of spontaneous intracranial hypotension (51H). Surgical ligation of CVF has been reported, but clinical outcomes are not well described. OBJECTIVE: To determine the clinical efficacy of surgical ligation for treatment of CVF. METHODS: Outcomes metrics were collected in this prospective, single-arm, cross-sectional investigation. Inclusion criteria were as follows: diagnosis of SIH, demonstration of CVF on myelography, and surgical treatment of CVF. Pre- and postoperative headache severity was assessed with the Headache Impact Test (HIT-6), a validated headache scale ranging from 36 (asymptomatic) to 78 (most severe). Patient satisfaction with treatment was measured with Patient Global Impression of Change (PGIC). RESULTS: Twenty subjects were enrolled, with mean postoperative follow-up at 16.0 +/- 9.7 mo. All CVFs were located in the thoracic region (between T4 and T12). Pretreatment headache severity was high (mean HIT-6 scores 65 +/- 6). Surgical treatment resulted in marked improvement in headache severity (mean HIT-6 change of -21 +/- -9, mean postoperative HIT-6 of 44 +/- 8). Of subjects with baseline headache scores in the most severe category, 83% showed a major improvement in severity (transition to the lowest 2 severity categories) after surgery. All subjects (100%) reported clinically significant levels of satisfaction with treatment (PGIC score 6 or 7); 90% reported the highest level of satisfaction. There were no short- or long-term complications or 30-d readmissions. CONCLUSION: Surgical ligation is highly effective for the treatment of SIH due to CVF. Larger controlled trials with longer follow-up period are indicated to better assess its longterm efficacy and safety profile.