{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T00:29:39Z","timestamp":1786494579650,"version":"build-2736575974"},"reference-count":9,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","license":[{"start":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T00:00:00Z","timestamp":1786320000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,8,10]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>CSF-venous fistula (CVF) is an increasingly recognized cause of CSF leakage resulting in spontaneous intracranial hypotension (SIH). CVFs are most commonly identified in the thoracolumbar spine and are rarely reported in the sacral region.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>A man in his 60s presented with symptoms consistent with SIH. CT of the brain demonstrated bilateral subdural hematomas and a decreased pontomesencephalic angle. Spinal MRI showed degenerative changes without evidence of a CSF leak. Lateral decubitus CT myelography (CTM) with delayed imaging identified a sacral CVF at the L5\u2013S1 level, which was confirmed with an adjusted technique within digital subtraction myelography (DSM). The fistula was determined to be the etiology of the patient\u2019s symptoms. Transvenous embolization via femoral venous access using Onyx-18 resulted in successful obliteration of the fistula.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>This case represents only the third reported sacral CVF. It highlights the importance of advanced diagnostic imaging when routine studies are negative but clinical suspicion for SIH remains high. Key technical considerations for CTM and DSM of the lumbosacral junction and sacrum are discussed.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE2632\">https:\/\/thejns.org\/doi\/10.3171\/CASE2632<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case2632","type":"journal-article","created":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T00:01:14Z","timestamp":1786492874000},"source":"Crossref","is-referenced-by-count":0,"title":["Sacral CSF-venous fistula: a rare entity. Illustrative case"],"prefix":"10.3171","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-3869-0758","authenticated-orcid":true,"given":"Alexander","family":"Mastrolonardo","sequence":"first","affiliation":[{"name":"Department of Clinical Neurological Sciences, Western University, London, Ontario"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annika R.","family":"Mascarenhas","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurological Sciences, Western University, London, Ontario"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keith","family":"MacDougall","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurological Sciences, Western University, London, Ontario"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Prateek","family":"Malik","sequence":"additional","affiliation":[{"name":"Department of Medical Imaging, Western University, London, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Mayich","sequence":"additional","affiliation":[{"name":"Department of Medical Imaging, Western University, London, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4958-3628","authenticated-orcid":true,"given":"Sachin","family":"Pandey","sequence":"additional","affiliation":[{"name":"Department of Medical Imaging, Western University, London, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"bib1","series-title":"Surg Neurol Int","article-title":"Spontaneous spinal cerebrospinal fluid venous-fistula treated with transvenous embolization: a case report","volume":"12","author":"Aljuboori","year":"2021","unstructured":"Aljuboori ZMcGrath MEssibayi MAZaidi SHallam DGhodke B.Spontaneous spinal cerebrospinal fluid venous-fistula treated with transvenous embolization: a case report. Surg Neurol Int. 2021;12:492. doi:10.25259\/SNI_878_2021"},{"key":"bib2","series-title":"World Neurosurg","first-page":"91","article-title":"Surgical treatment efficacy of CSF-venous fistulas: systematic review","volume":"161","author":"Konovalov","year":"2022","unstructured":"Konovalov AGadzhiagaev VVinogradov ENikitin NEliava SKonovalov N.Surgical treatment efficacy of CSF-venous fistulas: systematic review. World Neurosurg. 2022;161:91-96. doi:10.1016\/j.wneu.2022.02.036"},{"issue":"5","key":"bib3","series-title":"Neurosurgery","first-page":"931","article-title":"Cerebrospinal fluid-venous fistulas: a systematic review and examination of individual patient data","volume":"88","author":"Shlobin","year":"2021","unstructured":"Shlobin NAShah VNChin CTDillon WPTan LA.Cerebrospinal fluid-venous fistulas: a systematic review and examination of individual patient data. Neurosurgery. 2021;88(5):931-941. doi:10.1093\/neuros\/nyaa558"},{"issue":"6","key":"bib4","series-title":"AJNR Am J Neuroradiol","first-page":"740","article-title":"Utility of photon-counting detector CT myelography for the detection of CSF-venous fistulas","volume":"44","author":"Madhavan","year":"2023","unstructured":"Madhavan AAYu LBrinjikji WUtility of photon-counting detector CT myelography for the detection of CSF-venous fistulas. AJNR Am J Neuroradiol. 2023;44(6):740-744. doi:10.3174\/ajnr.A7887"},{"issue":"6","key":"bib5","series-title":"AJR Am J Roentgenol","first-page":"1418","article-title":"CSF-venous fistulas: anatomy and diagnostic imaging","volume":"217","author":"Kranz","year":"2021","unstructured":"Kranz PGGray LMalinzak MDHouk JLKim DKAmrhein TJ.CSF-venous fistulas: anatomy and diagnostic imaging. AJR Am J Roentgenol. 2021;217(6):1418-1429. doi:10.2214\/ajr.21.26182"},{"issue":"10","key":"bib6","series-title":"AJNR Am J Neuroradiol","first-page":"1544","article-title":"Resisted inspiration: a new technique to aid in the detection of CSF-venous fistulas","volume":"43","author":"Mark","year":"2022","unstructured":"Mark ITAmans MRShah VNResisted inspiration: a new technique to aid in the detection of CSF-venous fistulas. AJNR Am J Neuroradiol. 2022;43(10):1544-1547. doi:10.3174\/ajnr.A7636"},{"issue":"12","key":"bib7","series-title":"AJNR Am J Neuroradiol","first-page":"1824","article-title":"Sacral CSF-venous fistulas and potential imaging techniques","volume":"43","author":"Mark","year":"2022","unstructured":"Mark ITMorris PPBrinjikji WMadhavan AACutsforth-Gregory JKVerdoorn JT.Sacral CSF-venous fistulas and potential imaging techniques. AJNR Am J Neuroradiol. 2022;43(12):1824-1826. doi:10.3174\/ajnr.A7699"},{"issue":"8","key":"bib8","series-title":"AJNR Am J Neuroradiol","first-page":"994","article-title":"Resisted inspiration improves visualization of CSF-venous fistulas in spontaneous intracranial hypotension","volume":"44","author":"Kranz","year":"2023","unstructured":"Kranz PGMalinzak MDGray LWillhite JAmrhein TJ.Resisted inspiration improves visualization of CSF-venous fistulas in spontaneous intracranial hypotension. AJNR Am J Neuroradiol. 2023;44(8):994-998. doi:10.3174\/ajnr.A7927"},{"issue":"24","key":"bib9","series-title":"Neurology","first-page":"2310","article-title":"Spinal CSF venous fistula: a treatable etiology for CSF leaks in craniospinal hypovolemia","volume":"86","author":"Kumar","year":"2016","unstructured":"Kumar NDiehn FECarr CMSpinal CSF venous fistula: a treatable etiology for CSF leaks in craniospinal hypovolemia. 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