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PubMed This is a summary of 16 peer-reviewed journal articles Updated
Neurology

Imaging & Diagnostic Tests

At a Glance

Superficial siderosis is evaluated with iron-sensitive brain MRI and whole-spine imaging to show iron deposits and locate an ongoing bleed. Specialized leak imaging may find hidden spinal leaks, while lumbar puncture is not routinely needed and can carry leak risk.

The diagnosis of superficial siderosis relies heavily on medical imaging, combined with a clinical neurological examination. Because the iron deposits that define this condition are very thin and located on the outer surfaces of the brain and spine, standard MRI scans can sometimes miss them [1]. Specialized techniques are required to “see” the iron and, more importantly, to find where the blood is coming from.

Iron-Sensitive MRI

A standard MRI sequence, while useful for many conditions, may only show a thin or faint outline of the iron in superficial siderosis [1]. To evaluate the diagnosis, neurologists use “iron-sensitive” sequences that make these deposits much more visible:

  • Susceptibility-Weighted Imaging (SWI): This sequence highlights the way iron interferes with the magnetic field, making the deposits appear as a dark, thick “rim” around the brain or spinal cord [2][3].
  • T2 Gradient-Echo:* Like SWI, this sequence is highly effective at showing the pial hypointense rim (the dark line of iron on the surface) [1][4].

Why You Need a Whole-Spine MRI

If you have been diagnosed with the classical (infratentorial) form of the disease, your medical team should perform an MRI of your entire spine, even if your only symptoms are hearing loss or balance issues [5][6].

In a high percentage of classical cases, the source of the bleeding is a tiny tear in the dura (the protective lining of the spine), a tumor, or a vascular malformation [7]. Finding this source is critical because, unlike the iron already on your brain, an ongoing source is often something doctors can intervene on [5].

Pinpointing the Leak: Dynamic Imaging

Sometimes, a standard spine MRI shows evidence of a leak—such as a collection of fluid outside the dura called a SLEC—but cannot find the exact hole [8][9]. In these cases, experienced centers may use “dynamic” imaging to watch the fluid move:

  • Dynamic CT Myelography: This involves injecting a contrast dye into the spinal fluid and taking a rapid series of CT scans. It is excellent at finding “fast” leaks and can show if a tiny bone spur (an osteophyte) is the cause of the tear [10][11].
  • Digital Subtraction Myelography (DSM): This is a high-speed X-ray technique that can find very subtle or “hidden” leaks, including CSF-venous fistulas (abnormal connections between the spinal fluid and a vein) that standard MRIs often miss [12][13].

Important Note on Risks: Both CT Myelography and DSM are invasive procedures that involve radiation, contrast dye, and a needle puncture into the spinal canal. They should be selected carefully by experienced centers based on your specific MRI patterns.

The Role of CSF Analysis (Lumbar Puncture)

Your doctor may mention a “spinal tap” or lumbar puncture to analyze your CSF.

  • Ferritin and Bilirubin: High levels of these proteins in the CSF can indicate that bleeding has occurred [14].
  • Xanthochromia: This is a yellowing of the spinal fluid caused by the breakdown of red blood cells [15][2].

Proceed with caution: A lumbar puncture is not routine or strictly required to confirm a diagnosis of superficial siderosis if the MRI is clear. In fact, for patients who might have a spinal dural defect, a lumbar puncture can be risky because the needle puncture can create a new CSF leak or worsen an existing one [16]. It should only be performed if a specialist expects it to directly change your management plan, and the risks and alternatives should be clearly explained to you.

Common questions in this guide

What MRI sequences can show superficial siderosis?
Susceptibility-weighted imaging, or SWI, and T2* gradient-echo sequences are sensitive to the magnetic effects of iron. They can make the thin dark rim on the surfaces of the brain and spinal cord easier to see than a standard MRI.
Why might I need an MRI of my entire spine after a superficial siderosis diagnosis?
An entire-spine MRI can look for a small tear in the dura, a tumor, or a vascular malformation that is causing ongoing bleeding. Finding the source matters because some causes may be treatable.
What does a SLEC mean on a spine MRI?
SLEC stands for spinal longitudinal extradural cerebrospinal-fluid collection, meaning spinal fluid has collected outside the dura, the protective lining around the spinal cord. It can point to a spinal leak, although additional dynamic imaging may be needed to locate the exact opening.
What tests can find a spinal leak when a regular MRI does not show the exact hole?
Dynamic CT myelography and digital subtraction myelography can capture fluid movement and may detect fast or hidden leaks. They can also identify a bone spur causing a dural tear or a connection between spinal fluid and a vein, but they are invasive and should be selected by experienced specialists.
Is a lumbar puncture needed to diagnose superficial siderosis?
A lumbar puncture is not routinely required when MRI clearly shows superficial siderosis. Testing spinal fluid for ferritin, bilirubin, or yellow discoloration can support evidence of bleeding, but the puncture may create or worsen a spinal-fluid leak, so it should be considered only when the results are expected to change care.
What are the risks of CT myelography and digital subtraction myelography?
Both tests require a needle into the spinal canal and involve radiation and contrast dye. Because they are invasive, a specialist should weigh the chance of finding a treatable leak against the risks and your MRI findings.

Questions For You

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Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Does my brain MRI include iron-sensitive sequences like SWI (Susceptibility-Weighted Imaging) or T2*?
  2. 2.Has my entire spine been imaged to look for a 'SLEC' (spinal longitudinal extradural CSF collection)?
  3. 3.If my spine MRI was negative, should we consider dynamic CT myelography or digital subtraction myelography (DSM) to find a hidden leak?
  4. 4.What are the specific risks of undergoing a CT myelogram or DSM in my case?
  5. 5.Are my findings consistent with a 'diskogenic' dural defect caused by a bone spur or a calcified disc?

References

References (16)
  1. 1

    [Superficial siderosis of the central nervous system caused by myxopapillary ependymoma of conus medullaris and cauda equine: a case report and literature review].

    Xu L, Hu MJ, Li YY, et al.

    Beijing da xue xue bao. Yi xue ban = Journal of Peking University. Health sciences 2019; (51(4)):769-774 doi:10.19723/j.issn.1671-167X.2019.04.031.

    PMID: 31420638
  2. 2

    Clinical retrospective analysis of 14 cases of superficial siderosis of the central nervous system.

    Ji Y, Raza HK, Xu B, et al.

    BMC neurology 2026; (26(1)).

    PMID: 41840521
  3. 3

    Susceptibility-weighted Imaging: Technical Essentials and Clinical Neurologic Applications.

    Haller S, Haacke EM, Thurnher MM, Barkhof F

    Radiology 2021; (299(1)):3-26 doi:10.1148/radiol.2021203071.

    PMID: 33620291
  4. 4

    [Superficial Siderosis].

    Ohira M, Takao M

    Brain and nerve = Shinkei kenkyu no shinpo 2018; (70(10)):1107-1113 doi:10.11477/mf.1416201143.

    PMID: 30287696
  5. 5

    Infratentorial superficial siderosis: Classification, diagnostic criteria, and rational investigation pathway.

    Wilson D, Chatterjee F, Farmer SF, et al.

    Annals of neurology 2017; (81(3)):333-343 doi:10.1002/ana.24850.

    PMID: 28019651
  6. 6

    CNS Superficial Siderosis Mimicking a Motor Neuron Disease.

    Castro-Gomez S, Binder J, Schievelkamp AH, Heneka MT

    Brain sciences 2022; (12(11)) doi:10.3390/brainsci12111558.

    PMID: 36421882
  7. 7

    Spinal dural leaks in patients with infratentorial superficial siderosis of the central nervous system-Refinement of a diagnostic algorithm.

    Friedauer L, Rezny-Kasprzak B, Steinmetz H, et al.

    European journal of neurology 2022; (29(4)):1136-1144 doi:10.1111/ene.14611.

    PMID: 33098710
  8. 8

    Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks.

    Matsuhashi A, Takai K, Taniguchi M

    Journal of neurosurgery. Spine 2021; (34(3)):522-530 doi:10.3171/2020.6.SPINE20487.

    PMID: 33186904
  9. 9

    Spontaneous intracranial hypotension: diagnostic and therapeutic workup.

    Luetzen N, Dovi-Akue P, Fung C, et al.

    Neuroradiology 2021; (63(11)):1765-1772 doi:10.1007/s00234-021-02766-z.

    PMID: 34297176
  10. 10

    Diskogenic Dural Defect Is the Reason for the Ventral Location of the Epidural Spinal Fluid Collection Seen in Superficial Siderosis.

    Kumar N

    Neurology. Clinical practice 2021; (11(4)):e508-e515 doi:10.1212/CPJ.0000000000001085.

    PMID: 34484949
  11. 11

    Digital Subtraction Myelography for the Detection of Type 1 Spinal CSF Leaks: Evaluation of Temporal Characteristics and Diagnostic Value.

    Lützen N, Volz F, El Rahal A, et al.

    AJNR. American journal of neuroradiology 2025; (46(12)):2665-2672 doi:10.3174/ajnr.A8847.

    PMID: 40409982
  12. 12

    Prone Digital Subtraction Myelography vs Dynamic CT Myelography for Detecting Definite Type 1 CSF Leak in Spontaneous Intracranial Hypotension.

    Ha WS, Joo H, Cho S, et al.

    AJNR. American journal of neuroradiology 2026; (47(10)):2665-2673 doi:10.3174/ajnr.A9299.

    PMID: 41862186
  13. 13

    Lateral decubitus digital subtraction myelography to identify spinal CSF-venous fistulas in spontaneous intracranial hypotension.

    Schievink WI, Maya MM, Moser FG, et al.

    Journal of neurosurgery. Spine 2019; (31(6)):902-905 doi:10.3171/2019.6.SPINE19487.

    PMID: 31518974
  14. 14

    Cerebrospinal fluid biomarkers of superficial siderosis in patients with spontaneous intracranial hypotension.

    Häni L, Fung C, Jesse CM, et al.

    European journal of neurology 2023; (30(1)):235-240 doi:10.1111/ene.15591.

    PMID: 36209476
  15. 15

    Spinal CSF-Venous Fistulas as the Potential Cause of Chronic Subarachnoid Hemorrhage: Superficial Siderosis and Adhesive Arachnoiditis.

    Schievink WI, Maya MM, Parikh SK, et al.

    AJNR. American journal of neuroradiology 2026; (47(6)):1709-1714 doi:10.3174/ajnr.A9179.

    PMID: 42209145
  16. 16

    Superficial siderosis: comparison of two cases indicates two distinct diagnostic entities. Illustrative cases.

    Krishnakumar A, Ghadiyaram A, Patel VC, et al.

    Journal of neurosurgery. Case lessons 2023; (5(22)).

    PMID: 37249139

This page explains imaging and spinal-fluid tests used to evaluate superficial siderosis for informational purposes only and does not constitute medical advice. Your neurologist or imaging specialist can help determine which tests are appropriate for you.