A124 Epidural navigation and SLEC catheterization in type 1 spontaneous intracranial hypotension

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Background/Introduction Spontaneous Intracranial Hypotension (SIH) caused by ventral dural tears is frequently associated with Spinal Longitudinal Extradural Collections (SLECs). Despite their clinical relevance, direct in vivo fluoroscopic characterization of the anterior epidural compartment and SLEC morphology remains poorly defined, limiting both diagnostic understanding and therapeutic planning. Objective/Purpose To assess the feasibility of wire-catheter epidural navigation for fluoroscopic access to the anterior epidural space and SLECs in patients with type 1 SIH, and to describe the resulting imaging patterns. Methods/Case Description Between June 2023 and March 2026, 21 consecutive patients with type 1 SIH and MRI-confirmed SLECs underwent attempted wire-catheter epidural navigation via a lumbar interlaminar approach. A hydrophilic guidewire and 4F catheter were used to perform a controlled dorso-ventral transition into the anterior epidural space. Feasibility of anterior epidural and SLEC cannulation was evaluated; therapeutic outcomes were not assessed. Results/Findings Anterior epidural and/or SLEC opacification was achieved in 15/21 cases (75%; 95% CI 51–91%). Anterior epidural injections showed a segmental pattern with radiolucent septations and periradicular extensions, while SLEC injections produced homogeneous ventral opacification without segmental organization. Navigation failed in 5 cases due to epidural scarring (n=2) or procedural discontinuation for suspected dural violation (n=3). Venous entry occurred in 15–25% of procedures. One case of subarachnoid opacification caused transient symptoms, resolving with conservative management. Discussion/Conclusions/Learning Points Wire-catheter epidural navigation is technically feasible and enables fluoroscopic access to the anterior epidural space and SLECs in most SIH patients. The distinct imaging patterns — metameric septations anteriorly versus homogeneous SLEC opacification — reflect underlying anatomical compartmentalization and may guide future therapeutic interventions such as targeted epidural blood patching.

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