Percutaneous placement of an external drain of the cisterna magna using interventional magnetic resonance imaging in a patient with a persistent cerebrospinal fluid fistula: technical case report

Cerebrospinal fluid diversion from the cisterna magna has been described previously but has largely been abandoned because of high complication rates and anatomic constraints. Situations still remain in which this may be the best or only alternative. We describe the use of interventional magnetic resonance imaging (iMRI) for the application of this largely forgotten procedure. A 28-year-old woman with a previously diagnosed malignant peripheral nerve sheath tumor of the thoracic spine presented with a refractory postoperative cerebrospinal fluid leak complicated by diffuse meningeal carcinomatosis. External lumbar drainage was unsuccessful because of complete tumor obliteration. An attempt at primary closure augmented with muscle flaps was also ineffective. Ventricular drainage was deferred because of concern for tumor seeding, thus necessitating a more aggressive approach. The patient was intubated and placed in the open iMRI portal in a lateral decubitus position. Under direct image guidance, a closed-tip lumbar catheter was inserted into the cisterna magna through an iMRI-compatible biopsy needle and then connected for external drainage. To our knowledge, this is the first described use of iMRI technology for catheterization of the cisterna magna for cerebrospinal fluid diversion. Moreover, iMRI technology should be considered in future applications of complex posterior fossa shunting procedures.