Why Your MRI Looks “Normal” but You Still Have a CSF Leak with Dr. Andrew Callen (Ep 193)

Spinal cerebral spinal fluid (CSF) leaks are significantly more common in those with connective tissue disorders than many realize, yet patients often suffer for years before finding the right diagnosis.

In this episode, neuroradiologist Dr. Andrew Callen joins Dr. Linda Bluestein and co-host Dr. Knight to discuss the complexities of CSF dynamics and the challenges of diagnosing leaks when routine imaging appears normal. Dr. Callen explains the different types of leaks, including the elusive CSF-venous fistula, and why common clinical assumptions, like the requirement of a low opening pressure, are often incorrect.

From the Bern Score to the critical differences between Chiari malformations and positional brain sag, this conversation provides an essential roadmap for patients and clinicians navigating the "unseen" world of intracranial hypotension.

Takeaways:

Cerebral Spinal Fluid Basics: CSF is a clear fluid that cushions the brain and spine and plays a vital role in metabolic function.

Three Major Leak Types: Leaks can occur via bone spurs poking the dura, nerve root tears (common in EDS), or CSF-venous fistulas where fluid drains into the bloodstream.

Atypical Presentation: While "orthostatic headaches" (worse when upright) are classic, many patients experience vestibular symptoms like ringing in the ears, muffled hearing, imbalance, or cognitive "brain fog".

The Pressure Myth: The vast majority of proven CSF leak patients do not have low opening pressure; it is a disease of low volume, not necessarily low pressure.

Chiari Misdiagnosis: Positional "brain sag" can look identical to a Chiari malformation on imaging, leading to inappropriate surgical treatments if not carefully evaluated.

The Bern Score: This probabilistic scoring system based on MRI findings helps radiologists determine how likely it is that a myelogram will successfully find a patient's leak.

Imaging Strategy: Clinicians should look beyond simple reports and request specific measurements, such as the optic nerve sheath diameter and the Bern Score, to build an evidence-based case.

Find the episode transcript here.

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