动态CT脊髓造影中胸腰交界区腹侧脑脊液漏显示不清：Trendelenburg体位与压力的影响
单中心回顾性队列纳入43例自发性颅内低压并确认腹侧脑脊液漏的患者，行俯卧Trendelenburg位动态CTM。5例仅在额外中立位扫描时漏口才明确（Trendelenburg假阴性），且全部位于T11-T12及T12-L1水平，T11-T12以上无假阴性；漏口垂直高度与假阴性相关。结论支持蛛网膜下腔压力影响漏口显示，建议胸腰段可疑漏且Trendelenburg位阴性或可疑时加扫中立位。
要点
- 胸腰交界区（T11-L1）腹侧漏在俯卧Trendelenburg位动态CTM易假阴性。
- Trendelenburg位阴性或可疑而临床高度怀疑漏时，加扫中立位可提高漏口显示。
- 漏口位置越低、骨盆抬高越陡，假阴性风险越高，阅片需警惕。
核心结论
- 俯卧Trendelenburg位动态CTM对腹侧脑脊液漏的显示存在可重复的节段依赖性，假阴性集中于下胸段及胸腰交界区，尤其髋部陡峭抬高时。
- 结果支持蛛网膜下腔压力在腹侧漏口显示中起作用。
研究设计与样本
- 单中心回顾性队列研究，纳入47例检查中的43例自发性颅内低压并确认腹侧脑脊液漏的患者。
- 所有患者行俯卧Trendelenburg位动态CTM，当初次Trendelenburg采集阴性或可疑时，选择性加扫中立位且不加额外对比剂。
- 仅在中立位图像上漏口才明确的检查定义为Trendelenburg假阴性（TFN）。
关键影像表现/征象
- TFN仅见于下胸段及胸腰交界区（T11-T12和T12-L1水平），更头侧水平未见TFN。
诊断标准与关键数值
- 漏口水平按T11-T12以上与T11-T12及以下二分，TFN分别为0/35与5/8，Fisher检验P < .001。
- 检查时漏口部位的垂直高度与TFN发生相关，即使在低水平漏口亚组内亦如此。
临床应用与阅片要点
- 对临床怀疑腹侧脑脊液漏而Trendelenburg位动态CTM阴性或可疑者，尤其漏口可能位于下胸段或胸腰交界区时，建议加扫中立位以改善漏口显示与定位。
- 阅片时注意骨盆抬高程度和漏口相对于枕骨大孔的垂直高度，低位置漏口假阴性风险更高。
局限性
- 单中心回顾性设计。
- 中立位扫描为选择性加扫，仅用于初始Trendelenburg位阴性或可疑的病例。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
英文原文（摘要）· 点击展开
BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension can be caused by CSF leakage into the epidural space. Dynamic CTM in the prone Trendelenburg position is highly sensitive for the detection of ventral dural tears, but we have observed reduced effectiveness at the thoracolumbar junction with steep pelvic elevation, which might be related to a reduced subarachnoid pressure in lower levels in this position. The purpose of this study was to compare the conspicuity of ventral leaks across spinal levels and to assess the relationship between leak conspicuity and the degree of pelvic elevation.
METHODS: We conducted a single-center retrospective cohort of patients with SIH and confirmed ventral spinal CSF leaks who underwent dCTM. All patients underwent CTM in prone Trendelenburg position. An additional acquisition in the neutral position and without additional contrast was obtained selectively when the initial Trendelenburg acquisition was negative or equivocal. Examinations in which the leak became definite only on imaging obtained in the neutral position were classified as Trendelenburg false-negative. TFN frequency was analyzed according to spinal level and the relative height of the leak site with respect to the foramen magnum in the examination position.
RESULTS: Of 47 examinations, 43 met the inclusion criteria and were confirmed to have well-localized ventral CSF leaks. TFN occurred in 5/43 examinations and was observed exclusively at lower thoracic levels and the thoracolumbar junction (T11-T12 and T12-L1 levels), with no TFN identified at more cranial levels. When leak levels were dichotomized as above or at/below T11-T12, TFN occurred in 0/35 versus 5/8 examinations, respectively (Fisher test p < .001). The vertical height of the leak site during the examination was associated with TFN occurrence, even within the subgroup of low-level leaks.
CONCLUSIONS: Trendelenburg prone dCTM demonstrated a reproducible, level-dependent visualization pattern, with false-negatives clustering at lower thoracic levels and the thoracolumbar junction, particularly at steep hip elevations. These findings support the role of subarachnoid pressure in ventral leak conspicuity on CTM. When a ventral leak is suspected and the Trendelenburg acquisition is negative or equivocal, adding a neutral acquisition may improve leak visualization and localization at the thoracolumbar junction.
引用
- Brambilla VR, Silva GM, Edelmuth DGL, et al. Low Conspicuity of Ventral Spinal CSF Leaks in the Thoracolumbar Junction in Dynamic CT Myelography: Influence of Trendelenburg Position and Pressure. AJNR Am J Neuroradiol. 2026. PMID: 42134994. doi:10.3174/ajnr.A9414
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。