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Images from a spinal ependymoma extending from twelfth thoracic to the third lumbar vertebral level will be discussed, together with the history and the final outcome of a highly metastatic neuroepithelial tumor. The young female patient some weeks after laminectomy was diagnosed with multiple metastases, in the form of miliary mottling in both lungs, as well as with left pleural involvement with massive effusion and a solid formation in the right mammary gland. Although ependymomas rarely metastasize, a tight follow-up regimen and thorough screening is advisable, since case reports of multiple metastases via diverse routes (seeding, hematogenous) are becoming frequent and of concern.

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of childhood. Enthesitis-related arthritis (ERA) has been one of the most controversial subtypes of JIA with a higher risk of axial involvement. Our aim was to assess the frequency and spectrum of MRI findings of spine involvement in patients with JIA and determine if the axial involvement is always clinically symptomatic in patients with positive MRI findings. In this retrospective cross-sectional observational study we included known or suspected JIA patients who underwent spinal MRI examination between 2015 and 2017 and followed up in the Pediatric Rheumatology outpatient clinic. The demographic and clinical data were reviewed from the medical charts and electronic records. All patients were grouped as clinically symptomatic and asymptomatic for spinal involvement and MRI findings were re-evaluated for presence of inflammatory and erosive lesions. Of the 72 JIA patients, 57 (79.2%) were diagnosed with ERA, and 15 (20.8%) with non-ERA subtypes of JIA. Overall, 49 (68%) patients with JIA had positive spinal MRI findings (inflammatory and/or erosive lesions). Twenty-seven (47%) ERA patients were clinically symptomatic for spine involvement and among them, 19 (70.3%) had positive spinal MRI findings. Although 30 ERA (53%) patients were clinically asymptomatic, 23 of them (77%) had positive spinal MRI findings, as well. Eleven (73%) patients diagnosed with non-ERA JIA subtypes were clinically symptomatic for spine involvement at the time of MRI. Among them, four (36.3%) had inflammatory and/or erosive lesions on spine MRI. Four (26%) non-ERA patients were clinically asymptomatic for spine involvement, but three (75%) of them showed positive findings on spinal MRI. Inflammatory and/or erosive lesions of the thoracolumbar spine could exist in patients with JIA, regardless of the presence of symptoms. Not only because the significant proportion of ERA patients show asymptomatic axial involvement but also the presence of axial involvement in patients who were classified as non-ERA depending on current ILAR classification underlines the necessity of using MRI for accurate classification of patients with JIA.

OBJECTIVE The objective of this study was to assess the prevalence and spectrum of spinal dysraphism in a cohort of children with cloacal exstrophy (CEX) using MRI. METHODS Children with CEX presenting between 1999 and 2019 with baseline spinal MRI were included. The images were reviewed in consensus to assess the type of dysraphism. The dysraphisms were initially reviewed and described based on their descriptive anatomy, and then classified according to anomalies of gastrulation, primary neurulation, or secondary neurulation. RESULTS Thirty-four children were included. Thirty-three of these children had closed spinal dysraphism, and 1 had a normal spine. Of the 33 cases of closed spinal dysraphism, the conus and/or filum terminale were involved in all cases. The most common malformations were spinal lipoma (n = 20) and terminal myelocystocele (n = 11). The lipomas were heterogeneous: 4 dorsal, 9 transitional, 4 chaotic, and 3 terminal. A large subgroup (10/20, 50%) within the lipomas had an unusual morphology of noncontiguous double lipomas, the proximal fat related to the conus and the distal fat within the filum. These were difficult to characterize using existing classifications. In 2 cases, only a thickened filum was noted. The majority of these malformations were compatible with a disorder of secondary neurulation. CONCLUSIONS Complex spinal dysraphisms are consistently associated with CEX. The unusual dysraphism patterns found in this group of patients highlight the limitations of current embryological classifications. Given the propensity for neurological deterioration in this group of patients, spinal MRI should be routinely performed. The type and distribution of malformations seen have implications for the wider understanding of the pathogenesis and classification of lumbosacral lipomas.

Background Generally, asymptomatic epidermoid cysts (ECs) or ECs with minor symptoms controlled by medication are not treated further. Although epidermoid carcinomas are only sporadically reported, the possibility of malignant transformation of ECs is of concern. Case Description A 77-year-old man under observation for a left cerebellopontine angle tumor presented with no symptoms, including headache, dizziness, or other cranial nerve abnormalities typical of cerebellopontine angle tumors. The tumor manifested as an extra-axial mass in the left cerebellopontine angle and measured 24 × 16 mm (length × width) on magnetic resonance imaging (MRI). As he was asymptomatic, his primary physician did not pursue invasive treatment but ordered follow-up MRI every 2 years. The tumor decreased in size 2 years after the initial MRI, and no tumor fragmentation was observed on the patient’s spinal MRI. Ultimately, the tumor shrank to 19 × 11 mm over 22 years. Conclusions The reduction of an EC is extremely rare. We report a case of spontaneous regression of an EC and consider similar previous cases.

Background: Lateral meningocele is defined by the presence of protrusions of the arachnoid and the dura matter extending laterally through inter- or intravertebral foramina. It is an extremely rare condition; to the best of our knowledge, only a few cases are reported in the literature and most of them in childhood. Case presentation: Authors reported a case of a 48 years old lady who consulted for a lombo-sacral mass right-sided with a CSF fistula. The Spinal MRI objectified a meningocele lateralized in the right side associated with multiples malformations. The patient underwent surgery and the meningocele was closed after excision of the associated subcutaneous lipoma. The long term outcome was favourable and the follow up was assured by clinical examination monthly in the first year. Conclusion: Lateral meningocele is very rarely reported, it is usually associated with multiples malformations. Surgical treatment is a good option for treatment for avoiding complications. The prognostic depends on the preoperative status and the associated malformations.

OBJECTIVESolitary posterior fossa low-grade glial tumors (SPFLGT) in children are rarely associated with leptomeningeal dissemination (LMD). To date, there are no clear guidelines regarding the role of screening and surveillance spinal MRI (sMRI) in children with SPFLGT, at diagnosis or during follow-up periods. The current study reviews a cohort of children with SPFLGT, focusing on sMRI findings.METHODSIn this binational retrospective study, the authors analyzed 229 patients with SPFLGT treated and followed over 13 years. One hundred twelve children had at least 1 total sMRI screening or surveillance examination. One hundred seventeen had no sMRI, but did not present with clinical spinal signs or symptoms. Collected data included demographics, disease characteristics, radiology, pathology, and clinical follow-up data.RESULTSFor the 112 children with at least 1 sMRI, the mean duration from diagnosis to first sMRI was 11.73 ± 28.66 months (range 0–165 months). All sMRI scans were conducted as screening examinations, with no spinal-related symptoms. One patient was found to have a sacral intradural lesion concurrent to the brain tumor diagnosis. Over the course of 180 radiological and 533 clinical follow-up years for the 112 patients with sMRI, and 582 clinical follow-up years for the 117 patients with no sMRI, there were no additional cases with spinal tumor spread.CONCLUSIONSThe yield of screening sMRI in the absence of cranial metastasis, or spinal symptoms, is extremely low. Because preoperative sMRI is recommended for medulloblastomas and ependymomas, it may be logical to acquire. During the follow-up period the authors recommend limiting sMRI in patients without symptoms suggesting a spinal lesion, in patients without known cranial metastases, or recurrence or residual SPFLGT.

Lumbar spinal MRI has the advantage of providing a wealth of visible structures. The assessment of its signal intensities, however, can be challenging. This chapter supplies a systematic guide to assess lumbar spinal MRI scans. Furthermore, it gives an overview of signal intensities of diverse physiological and pathological entities.

Case summary A 10-year-old male neutered Russian Blue cat was presented with a 2-month history of progressive non-ambulatory paraparesis. Spinal MRI revealed a well-demarcated, compressive intradural extramedullary mass at the level of T1 vertebra. The mass had subtle hyperintensity on T2-weighted images, was isointense on T1-weighted images and had diffuse, marked enhancement following gadolinium administration. Neuroaxis MRI, including limited brain sequences, excluded other visible lesions. Thoracic and abdominal radiographs were unremarkable. The mass was resected via a dorsal C7–T2 laminectomy and durotomy. Histopathology revealed a neoplasm composed of columnar-to-polygonal cells forming bilayered palisading patterns with a few apical cilia. Three mitoses were noted in 10 high-power fields. This was consistent with an epithelial neoplasm and initially a metastatic adenocarcinoma was considered most likely. Full-body CT with contrast and including the brain found rhinitis but did not identify any additional neoplastic foci. Biopsies of the nasal cavity and fine-needle aspiration of the spleen and liver were unremarkable. On immunohistochemical evaluation, pan-cytokeratin and E-cadherin immunolabelling was observed; however, synaptophysin, thyroglobulin, chromogranin A and glial fibrillary acidic protein was not detected. This, along with the histological morphology and absence of a primary tumour, was compatible with an ectopic choroid plexus neoplasm. Follow-up performed at 3, 14 and 24 months postoperatively revealed neurological improvement without recurrence. Relevance and novel information We describe the presentation, histopathological and immunohistochemical features and outcome of a case of a rare ectopic choroid plexus neoplasm in the spinal cord of a cat.

Case report - Introduction This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren’s with lymphocytic interstitial nephritis and positive Sjogren’s autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in well-hydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points

A great number of radiologic reports are created each year which incorporate the expertise of radiologists. This knowledge could be exploited via machine understanding. This could provide valuable statistics and visualization of the reports, and as training data, and it could also contribute to later automatic reporting applications. In our current work, we present our first steps toward the machine understanding of clinical reports of the spinal region, written in the Hungarian language. Our system provides an automatic classification and connection detection for various entities in the text. Our classification is achieved via bi-directional long short-term memory and conditional random fields producing 0.87–0.95 F1-score values, while the extraction of connection relies on linguistic analysis and predefined rules. The extracted information is displayed in an easily comprehensible, well-formed tree-structure.

Spinal cord abscess is a rare entity, particularly in the pediatric population. Spinal cord abscesses can be located in extradural, subdural and intradural (intramedullary or extramedullary) regions of the cord. Among these locations, intramedullary is extremely uncommon. There have been few case reports of intramedullary spinal cord abscess since its first description in 1830. We describe a 2 year-old boy with a history of neonatal meningitis due to E.coli who presented with refusal to walk and was subsequently found to have intramedullary spinal cord abscesses at multiple levels. Culture of the abscesses again revealed E.coli. The patient was noted to have a pit located just superiorly to his sacral spine. Imaging revealed the presence of a dorsal dermal sinus tract. It is important to evaluate anatomical abnormalities, especially in the setting of serious bacterial infections, such as meningitis, as they have the potential to serve as a reservoir for infection.

Routine spinal MRI can be used for bone marrow lesions detection. The most useful standard pulse sequence is T1- WI, which helps both in local and diffuse bone marrow diseases. Additional new pulse sequences, including chemical shift imaging and diffusion weighted imaging, can be used as solving-problem techniques.

Approximately 25% of patients with anorectal malformation have tethered cord. The traditional way of determining conus medullaris level on magnetic resonance imaging (MRI) relies on counting vertebrae, which may be challenging due to vertebral numeric variation, segmentation anomalies, as well as transitional vertebral body anatomy. The purpose of this study was to utilize more reliable anatomic landmarks (foramen magnum, conus termination, and the upper limit of the iliac crest) to establish a consistent ratio that may differentiate patients with normal and low-lying conus.A single institution database search identified two groups of patients: 255 with normal and 85 with abnormal spinal MRI, who underwent tethered cord release. The conus medullaris ratio was calculated in both groups. The ratio was obtained by dividing the distance between the conus level and the iliac crest by the distance between the foramen magnum and the conus level (IRB # 16-2330).The mean ratio was significantly higher in the non-tethered group compared to the tethered patients (0.184 [sd 0.03] versus 0.118 [sd 0.09]; P.0001). The ratio proved to be a good discriminator between normal and abnormal patients, with area under the curve (AUC) equal to 0.749, meaning that at random, there is a 75% chance that the tethered cord patient will have a lower ratio than the non-tethered cord patient."The Conus Medullaris Ratio" is a good predictor of low-lying conus level on MRI and offers an easy alternative to counting vertebral body levels, particularly in patients with variant or abnormal vertebral body anatomy.II, Study of Diagnostic Test.

Objectives To study the presence of high signal intensity of the intervertebral disc, syndesmophytes, vertebral corner bridging and transdiscal ankylosis on spinal T1-weighted MR images in spondyloarthritis (SpA). Methods A retrospective case-control study of whole spine MRI examinations, obtained in 100 patients with axial SpA and in 100 control patients, was performed. All disco-vertebral units (DVUs) were analyzed on T1-weighted MR images for normal or high signal intensity of the intervertebral disc, presence of syndesmophytes, vertebral corner bridging or transdiscal ankylosis and correlated with final diagnosis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated. Results In this study group, intradiscal high signal intensity, vertebral corner bridging and transdiscal ankylosis on T1-weighted MR images of the spine were all highly specific (specificity: 100%) for diagnosis of axial SpA. However, these signs all had low sensitivity (vertebral corner bridging: 15.0%; intradiscal high signal intensity on T1-weighted MR images: 12.0%; transdiscal ankylosis: 8.0%). Syndesmophytes on spinal MRI were observed in 25 patients but had a more limited diagnostic value (sensitivity: 16.0%, specificity: 91.0%). Conclusions When present in a patient with inflammatory back pain, intradiscal high signal intensity on T1-weighted MR images could be a specific and reliable sign of the presence of axial SpA. Vertebral corner bridging and transdiscal ankylosis also show potential as specific and reliable signs of axial SpA. In contrast, syndesmophytes on MRI do not show potential as a specific or reliable sign of axial SpA.

A 59-year-old man presented with a 9-month history of progressive weakness and numbness in his lower extremities (grade 4/5). Spinal MRI demonstrated extensive edema in the spinal cord and prominent intramedullary enhancement. Selective angiography revealed a right L1 spinal dural arteriovenous fistula (SDAVF) with intradural double draining veins (figure 1). The fistula was treated with surgery successfully. The patient's symptoms gradually improved after surgery. Postoperative MRI showed significant resolution of the edema and enhancement (figure 2). SDAVF with intradural double draining veins is extremely rare.1,2 This case clearly showed a rare draining pattern of intradural double draining veins in SDAVF.

Pyogenic subdural spinal collections are rare but an important pathology to recognise and manage appropriately. We report the case of a 56-year-old female who developed a posterior subdural spinal collection associated with local discitis. There was no direct communication between the infected disc and subdural space, and the collection was located posteriorly within the subdural space which makes this case all the more unusual. We discuss the need for spinal subdural collections to be considered as a differential in patients with back pain and lower limb neurology (especially when there is a known spinal infective focus), the importance of careful interpretation of imaging, and the pathophysiological mechanisms and organisms known to cause spinal subdural collections.

With IRB approval, a total of 132 sagittal views of T1-weighted (T1W) sequence in the spinal MRI scans was collected from 67 patients at our institution and used in this study. We developed a similarity-consistency abnormality detection model (SCAD) for classification of MRI patterns that are associated with low and high risk of multiple myeloma (MM) disease. Our SCAD model consisted of five CNN structures: a generator, an encoder, and three discriminators. The generator was used to capture the distribution of training samples by mapping the given distributions to the distribution of training samples. The encoder mapped the distribution of training samples back to the given distribution to speed up the inference time. The three discriminators were designed to force the generator and the encoder to meet a cycleconsistency constraint. The five components are trained together following the min-max game in GAN. The MRI patterns of each vertebra (normal, focal, variegated and diffused) were provided by an experienced radiologist as reference standard. We trained our SCAD model using the vertebras with the normal pattern, and deployed the trained SCAD model to the three non-normal patterns. The results showed that, our SCAD model achieved a test AUC of 0.71, 0.79 and 0.88 in identifying the focal, variegated and diffused patterns from the normal pattern, respectively.

Purpose We sought to identify correlations between working diagnosis, surgeon indication for obtaining spinal MRI and positive MRI findings in paediatric patients presenting with spinal disorders or complaints. Methods Surgeons recorded their primary indication for ordering a spinal MRI in 385 consecutive patients. We compared radiologist-reported positive MRI findings with surgeon response, indication, working diagnosis and patient demographics. Results The most common surgeon-stated indications were pain (70) and coronal curve characteristics (63). Radiologists reported 137 (36%) normal and 248 (64%) abnormal MRIs. In total, 58% of abnormal reports (145) did not elicit a therapeutic or investigative response, which we characterized as ‘clinically inconsequential’. In all, 42 of 268 (16%) presumed idiopathic scoliosis patients had intradural pathology noted on MRI. Younger age (10.3 years versus 12.0 years) was the only significant demographic difference between patients with or without intradural pathology. Surgeon indication ‘curve magnitude at presentation’ was associated with intradural abnormality identification. However, average Cobb angles between patients with or without an intradural abnormality was not significantly different (39° versus 37°, respectively). Back pain without neurological signs or symptoms was a negative predictor of intradural pathology. Conclusion Radiologists reported a high frequency of abnormalities on MRI (64%), but 58% of those were deemed clinically inconsequential. Patients with MRI abnormalities were two years’ younger than those with a normal or inconsequential MRI. ‘Curve magnitude at presentation’ in presumed idiopathic scoliosis patients was the only predictor of intrathecal pathology. ‘Pain’ was the only indication significantly associated with clinically inconsequential findings on MRI. Level of evidence III

Emergent spinal MRI is recommended for patients with back pain and red flags for infection. However, many of these studies are negative due to low prevalence of spinal infections. Our purpose was to assess if C-reactive protein (CRP) can be used to guide effective utilization of emergent MRI for spinal infections. 316/960 (33%) MRIs performed for infection by the emergency department over 75-month period had CRP levels obtained at presentation, after excluding patients receiving antibiotic or had spinal surgery in 100 mg/L as highly elevated. CRP was normal in 95/316 (30%) and abnormal in 221/316 (70%) patients. MRI was positive in 43/316 (13.6%) patients, all of whom had abnormal CRP. CRP (p

Spinal subdural hematoma (SSDH) was rarely reported in association with COVID-19. A fifty-five-year-old febrile male was presented with sudden onset of areflexic paraparesis, urinary retention, loss of all sensations below the twelve spinal thoracic segment, and severe back pain. COVID-19 was confirmed by positive RT-PCR and spinal MRI showed SSDH.

Highlights • Neuro sweet disease (NSD) rarely exhibits spinal cord involvement. • We experienced a case of NSD with longitudinally extensive transverse myelitis. • The shape of gadolinium enhanced lesion of spinal MRI was characteristic. • Above mentioned finding might be useful for diagnosis of neuro sweet disease.

It has been described that patients with more complex anorectal malformations (ARM), lower sacral ratios and spinal anomalies have poorer rates of fecal and urinary continence. While the ARM subtype has been shown to be an independent predictor of fecal continence, it is not well understood how each of these anatomic factors impact urinary continence. The purpose of this study was to identify anatomic factors associated with urinary continence in children born with ARM. We performed a retrospective review of a large prospectively collected database of children with ARM. Inclusion criteria included diagnosis of ARM, age4 years, available lateral sacral ratio measurement and presence of spinal MRI. Any child with incomplete or absent continence data was excluded. Continence was defined as voiding per urethra volitionally, dry between voids and ≤1 urinary accident per week. Bivariable tests of association and log-binomial regression models were used to examine association between anatomic factors and urinary continence. A total of 434 patients were included in the study. 57.8% (n = 251) were male. Median age was 8.4 years (IQR 6.0-12.3). With regards to severity of ARM, 20.3% (n = 88) were complex, 23.3% (n = 101) were moderate and 56.5% (n = 245) were simple. Lateral sacral ratio included 11.1% (n = 48) that were0.4, 36.2% (n = 157) 0.4-0.7 and 52.8% (n = 229) 0.7. Spine status was found to be myelomeningocele in 4.4% (n = 19), low conus or tethered cord in 34.8% (n = 151) and normal or fatty filum in 60.8% (n = 264). Overall 62.2% were continent. ARM severity, lateral sacral ratio and spine status were each independent predictors of urinary continence on univariate and multivariable analysis. We conclude that in children born with ARM, the severity of ARM, lateral sacral ratio and spine status each independently predict urinary continence. These results allow us to better understand these complex patients and their ability to develop urinary continence. This is crucial in enabling proper patient and family counseling and thus, setting appropriate expectations.

Objectives Several brain and spinal magnetic resonance imaging signs have been described in spontaneous intracranial hypotension. Their correlations are not fully studied. This study aimed to explore potential mechanisms underlying cerebral neuroimaging findings and to examine associations among spinal and brain magnetic resonance imaging signs. Methods We conducted a retrospective review of magnetic resonance myelography and brain magnetic resonance imaging records of patients with spontaneous intracranial hypotension. Categorical principal component analysis was employed to cluster brain neuroimaging findings. Spearman correlation was employed to analyze associations among different brain neuroimaging findings and between brain and spinal neuroimaging findings. Results In patients with spontaneous intracranial hypotension (n = 148), categorical principal component analysis of brain neuroimaging signs revealed two clusters: Cerebral venous dilation and brain descent. Among all brain magnetic resonance imaging signs examined, only midbrain-pons angle associated with anterior epidural cerebrospinal fluid collection length (surrogate spinal cerebrospinal fluid leak severity) (n = 148, Spearman’s ρ = −0.38, p Conclusion This study indicates that there are two factors behind the brain neuroimaging findings in spontaneous intracranial hypotension: Cerebral venous dilation and brain descent. Certain brain neuroimaging signs correlate with spinal cerebrospinal fluid leakage severity, depending on different circumstances.