Evaluation of the C1-C2 False Localizing Sign in Spontaneous Intracranial Hypotension: Prevalence and Clinical Insights
- 1From the Division of Neuroradiology (A.A.M., P.G.K., E.H.W, M.D.M., J.W., L.G., T.J.A.), Department of Radiology, Duke Health, Durham, North Carolina
- 2Division of Neuroradiology (M.L.K), Department of Radiology, Mayo Clinic, Rochester, Minnesota
Abstract
BACKGROUND AND PURPOSE: Dural tears are a major cause of spontaneous intracranial hypotension (SIH). The existence of a dural tear can be inferred by the presence of extradural CSF on spine MRI. However, extradural CSF usually spans multiple spinal levels, precluding localization of the dural tear on MRI. The C1-C2 false localizing sign (C1-C2 sign) refers to preferential pooling of extradural CSF dorsally at C1-C2, even though this is typically not the site of leak. Although this has been described as an important false localizing sign, other potentially important features of this imaging finding have not been studied. Here, we sought to estimate the prevalence of the C1-C2 sign in patients with spontaneous dural tears and determine whether the presence of the C1-C2 sign correlates with the length of disease. MATERIALS AND METHODS: We retrospectively identified all patients diagnosed with a dural tear on dynamic CT myelography at our institution between January 2024 and January 2026. We excluded patients who did not have SIH or lacked premyelographic spine MRI with T2-weighted fat-suppressed sequences. For patients in the final cohort, we recorded the time between symptom onset and initial spine MRI. The presence or absence of the C1-C2 sign on spine MRI was assessed by 2 neuroradiologists, with any disagreements adjudicated by a third neuroradiologist. The prevalence of the C1-C2 sign was calculated, and correlation with the length of symptoms before MRI was determined using logistic regression. RESULTS: < .05). Furthermore, we identified 11 patients who underwent 2 spine MRIs before myelography. In 6/11 patients, the C1-C2 sign was initially present and resolved over time. CONCLUSIONS: The C1-C2 false localizing sign is associated with a relatively shorter disease duration. Its presence may be helpful in determining optimal treatment strategies in patients with dural tears.
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BibTeX
@article{madhavan2026evaluation,
title = {{Evaluation of the C1-C2 False Localizing Sign in Spontaneous Intracranial Hypotension: Prevalence and Clinical Insights}},
author = {Ajay A. Madhavan and Peter G. Kranz and Michelle L. Kodet and E. Hope Weant and Michael D. Malinzak and Jay Willhite and Linda Gray and Timothy J. Amrhein},
journal = {AJNR: American Journal of Neuroradiology},
year = {2026},
month = nov,
doi = {10.3174/ajnr.a9309},
url = {https://doi.org/10.3174/ajnr.a9309},
note = {CC BY},
}
RIS
TY - JOUR
TI - Evaluation of the C1-C2 False Localizing Sign in Spontaneous Intracranial Hypotension: Prevalence and Clinical Insights
AU - Ajay A. Madhavan
AU - Peter G. Kranz
AU - Michelle L. Kodet
AU - E. Hope Weant
AU - Michael D. Malinzak
AU - Jay Willhite
AU - Linda Gray
AU - Timothy J. Amrhein
PY - 2026
DA - 2026/11/06
JO - AJNR: American Journal of Neuroradiology
DO - 10.3174/ajnr.a9309
UR - https://doi.org/10.3174/ajnr.a9309
AB - BACKGROUND AND PURPOSE: Dural tears are a major cause of spontaneous intracranial hypotension (SIH). The existence of a dural tear can be inferred by the presence of extradural CSF on spine MRI. However, extradural CSF usually spans multiple spinal levels, precluding localization of the dural tear on MRI. The C1-C2 false localizing sign (C1-C2 sign) refers to preferential pooling of extradural CSF dorsally at C1-C2, even though this is typically not the site of leak. Although this has been described as an important false localizing sign, other potentially important features of this imaging finding have not been studied. Here, we sought to estimate the prevalence of the C1-C2 sign in patients with spontaneous dural tears and determine whether the presence of the C1-C2 sign correlates with the length of disease. MATERIALS AND METHODS: We retrospectively identified all patients diagnosed with a dural tear on dynamic CT myelography at our institution between January 2024 and January 2026. We excluded patients who did not have SIH or lacked premyelographic spine MRI with T2-weighted fat-suppressed sequences. For patients in the final cohort, we recorded the time between symptom onset and initial spine MRI. The presence or absence of the C1-C2 sign on spine MRI was assessed by 2 neuroradiologists, with any disagreements adjudicated by a third neuroradiologist. The prevalence of the C1-C2 sign was calculated, and correlation with the length of symptoms before MRI was determined using logistic regression. RESULTS: < .05). Furthermore, we identified 11 patients who underwent 2 spine MRIs before myelography. In 6/11 patients, the C1-C2 sign was initially present and resolved over time. CONCLUSIONS: The C1-C2 false localizing sign is associated with a relatively shorter disease duration. Its presence may be helpful in determining optimal treatment strategies in patients with dural tears.
SN - 0195-6108
SN - 1936-959X
ER -