A Combination of Magnetic Resonance Imaging Techniques to Localize the Dural Defect in a Case of Superficial Siderosis-A Case Report.

Background: Superficial siderosis is a progressively disabling disease caused by recurrent subarachnoid hemorrhage with accumulation of hemosiderin in the surface of the central nervous system. Although a wide variety of conditions may cause superficial siderosis, approximately half of the cases are reported to be associated with a defect in the ventral spinal dura mater, in which case treatment entails surgical repair of the defect. Here, we report a case of superficial siderosis and report on our method to pinpoint the dural defect using a combination of magnetic resonance imaging (MRI) techniques. Methods and Results: A 74-year-old female presented suffering from hearing loss and progressive ataxia over a duration of seven years. A T2-weighted MRI study revealed hypointensity in the superficial areas of the central nervous system, leading to the diagnosis of superficial siderosis, and the presence of a fluid-filled collection in the anterior spinal canal of C7 to T10 suggested that a dural defect was the cause of the repeated hemorrhage. A balanced turbo field echo (BTFE) MRI sequence revealed possible dural defects at T1-T2 and T5-T6, and a dynamic improved motion-sensitized driven-equilibrium steady-state free precession (dynamic iMSDE SSFP) sequence revealed an irregular flow of cerebrospinal fluid through the dura at the T5-T6 level. The dural defect was confirmed and sutured through a minimal T5-T6 laminectomy without neurological consequences, and the patient reported mild improvement in gait one year after surgery. Conclusions: A combination of MRI sequences provided the necessary information to confidently perform minimal surgery to repair the dural defect. We recommend coupling a balanced steady-state free precession (SSFP) sequence to provide high resolution, high contrast images of anatomical structures and a dynamic iMSDE SSFP sequence to confirm cerebrospinal fluid motion through the defect.