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Kheram N, Bessen MA, Jones CF, Davies BM, Kotter M, Farshad M, Hupp M, Nanz D, Freund P, Schubert M, Kurtcuoglu V, Curt A, Zipser CM. Cerebrospinal fluid pressure dynamics as a biomechanical marker for quantification of spinal cord compression: Conceptual framework and systematic review of clinical trials. BRAIN & SPINE 2025; 5:104211. [PMID: 40041396 PMCID: PMC11879606 DOI: 10.1016/j.bas.2025.104211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Revised: 01/21/2025] [Accepted: 02/10/2025] [Indexed: 03/06/2025]
Abstract
Introduction In patients with acute spinal cord injury (SCI) and degenerative cervical myelopathy (DCM), spinal cord compression is considered a main contributor to spinal cord damage, associated with cerebrospinal fluid (CSF) space obstruction. CSF pressure (CSFP) dynamics are studied as a potential indirect biomechanical marker for spinal cord compression, and as a proxy to estimate spinal cord perfusion pressure (SCPP). Research question Evidence for safety and feasibility of CSFP dynamics in clinical trials as well as interrelations with neuroimaging and intraspinal pressure, and relation to preclinical CSFP models. Material and methods Systematic review. This review followed PRISMA guidelines, risk of bias assessment with ROBINS-I tool, PROSPERO registration (CRD42024545629). Results 11 relevant papers were identified (n = 212 patients, n = 194 intraoperative, n = 18 bedside). Risk of bias for safety reporting was low-moderate. Intraoperative CSFP assessments were commonly performed in acute SCI. CSFP was assessed to calculate SCPP (7/11), to evaluate effects from surgical decompression (5/11) and for therapeutic CSF drainage (3/11). The adverse event rate associated with the intrathecal catheter was 8% (n = 15/194). Discussion and conclusion The preliminary safety and feasibility profile of CSFP assessments in spinal cord compression encourages clinical application. However, a deeper risk-benefit analysis is limited as the clinical value is not yet determined, given challenges of defining disease specific critical CSFP and SCPP thresholds. The interrelation between measures of CSFP and neuroimaging is yet to be proven. Targeted preclinical studies are essential to improve our understanding of complex CSFP-cord compression interrelations.
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Affiliation(s)
- Najmeh Kheram
- Spinal Cord Injury Center and Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | | | - Claire F. Jones
- School of Electrical & Mechanical Engineering, The University of Adelaide, Adelaide, Australia
| | - Benjamin M. Davies
- Department of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Mark Kotter
- Department of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Mazda Farshad
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Spine Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Markus Hupp
- Spinal Cord Injury Center and Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Daniel Nanz
- Swiss Center for Musculoskeletal Imaging, Balgrist Campus AG, Zurich, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center and Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center and Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Vartan Kurtcuoglu
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center and Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Carl M. Zipser
- Spinal Cord Injury Center and Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Su H, Lan X, Cao Y, Zhang M, Chen X, Lan C. Cervical epidural blood patch treatment is a choice for spontaneous intracranial hypotension. Technol Health Care 2025; 33:567-575. [PMID: 39269870 DOI: 10.3233/thc-241366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
BACKGROUND Epidural blood patch (EBP) is a minimally invasive and effective treatment for spontaneous intracranial hypotension (SIH). But, cervical epidural blood patch for SIH has little attention. OBJECTIVE In this study, The clinical data was recorded and the treatment efficacy and safety of cervical EBP in SIH were evaluated. METHODS : Fifty-nine cases of intractable SIH were examined by computed tomography (CT) guided cervical EBP at the Chinese PLA General Hospital from August 2014 to March 2024. RESULTS The mean age of the fifty-nine patients at symptom onset was 40.8 ± 9.5 years. 54/59 (91.5%) patients experienced orthostatic headache. Preoperative spine T2 scans with extensive fluid collection at the upper cervical region in 43/46 (93.5%). 45/59 (76.3%) patients had symptomatic relief with initial cervical EBP, and 14/59 (23.7%) patients received further cervical EBPs. In the first one to three days following the EBP procedure, 11 (18.6%) patients reported pain at the puncture site and 15 (25.4%) experienced neck pain. No other complications were observed during or after the procedure. At the latest follow-up, all patients showed good recovery. The mean follow-up was 28.9 ± 22.7 months. CONCLUSION CT-guided cervical EBP is a effective and safe treatment for patients with intractable SIH, especially in patients who had extensive fluid collection at the upper cervical region.
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Affiliation(s)
- Hui Su
- Department of Neurology, Chinese PLA General Hospital First Medical Center, Beijing, China
| | - Xiaoyang Lan
- Department of Neurology, Chinese PLA General Hospital First Medical Center, Beijing, China
| | - Ya Cao
- Department of Neurology, Chinese PLA General Hospital First Medical Center, Beijing, China
| | - Mingjie Zhang
- Department of Neurology, Chinese PLA General Hospital First Medical Center, Beijing, China
| | - Xiaoyan Chen
- Department of Neurology, Chinese PLA General Hospital First Medical Center, Beijing, China
| | - Chen Lan
- Department of Anesthesiology, Chinese PLA General Hospital First Medical Center, Beijing, China
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Muccio M, Sun Z, Chu D, Damadian BE, Minkoff L, Bonanni L, Ge Y. The impact of body position on neurofluid dynamics: present insights and advancements in imaging. Front Aging Neurosci 2024; 16:1454282. [PMID: 39582951 PMCID: PMC11582045 DOI: 10.3389/fnagi.2024.1454282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 10/29/2024] [Indexed: 11/26/2024] Open
Abstract
The intricate neurofluid dynamics and balance is essential in preserving the structural and functional integrity of the brain. Key among these forces are: hemodynamics, such as heartbeat-driven arterial and venous blood flow, and hydrodynamics, such as cerebrospinal fluid (CSF) circulation. The delicate interplay between these dynamics is crucial for maintaining optimal homeostasis within the brain. Currently, the widely accepted framework for understanding brain functions is the Monro-Kellie's doctrine, which posits a constant sum of intracranial CSF, blood flow and brain tissue volumes. However, in recent decades, there has been a growing interest in exploring the dynamic interplay between these elements and the impact of external factors, such as daily changes in body position. CSF circulation in particular plays a crucial role in the context of neurodegeneration and dementia, since its dysfunction has been associated with impaired clearance mechanisms and accumulation of toxic substances. Despite the implementation of various invasive and non-invasive imaging techniques to investigate the intracranial hemodynamic or hydrodynamic properties, a comprehensive understanding of how all these elements interact and are influenced by body position remains wanted. Establishing a comprehensive overview of this topic is therefore crucial and could pave the way for alternative care approaches. In this review, we aim to summarize the existing understanding of intracranial hemodynamic and hydrodynamic properties, fundamental for brain homeostasis, along with factors known to influence their equilibrium. Special attention will be devoted to elucidating the effects of body position shifts, given their significance and remaining ambiguities. Furthermore, we will explore recent advancements in imaging techniques utilized for real time and non-invasive measurements of dynamic body fluid properties in-vivo.
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Affiliation(s)
- Marco Muccio
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, United States
| | - Zhe Sun
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, United States
| | - David Chu
- FONAR Corporation, Melville, NY, United States
| | - Brianna E. Damadian
- Department of Radiology, Northwell Health-Lenox Hill Hospital, New York, NY, United States
| | | | | | - Yulin Ge
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, United States
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Tomita Y, Yagi M, Seki F, Komaki Y, Matsumoto M, Nakamura M. Cerebrospinal Fluid Dynamics Analysis Using Time-Spatial Labeling Inversion Pulse (Time-SLIP) Magnetic Resonance Imaging in Mice. J Clin Med 2024; 13:4550. [PMID: 39124818 PMCID: PMC11312514 DOI: 10.3390/jcm13154550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 07/26/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: Abnormalities in cerebrospinal fluid (CSF) dynamics cause diverse conditions, such as hydrocephalus, but the underlying mechanism is still unknown. Methods to study CSF dynamics in small animals have not been established due to the lack of an evaluation system. Therefore, the purpose of this research study is to establish the time-spatial labeling inversion pulse (Time-SLIP) MRI technique for the evaluation of CSF dynamics in mice. Methods: We performed the Time-SLIP technique on 10 wild-type mice and 20 Tiptoe-walking Yoshimura (TWY) mice, a mouse model of ossification of the posterior longitudinal ligament (OPLL). We defined the stir distance as the distance of CSF stirring and calculated the mean ± standard deviation. The intraclass correlation coefficient of intraobserver reliability was also calculated. Furthermore, in TWY mice, the correlation coefficient between stir distance and canal stenosis ratio (CSR) was calculated. Results: The stir distance was significantly lower in TWY mice at 12 weeks and 17 weeks of age (1.20 ± 0.16, 1.21 ± 0.06, and 1.21 ± 0.15 mm at 12 weeks and 1.32 ± 0.21, 1.28 ± 0.23, and 1.38 ± 0.31 mm at 17 weeks for examiners A, B, and C). The intrarater reliability of the three examiners was excellent (>0.90) and there was a strongly negative correlation between stir distance and CSR in TWY mice (>-0.80). Conclusions: In this study, we established the Time-SLIP technique in experimental mice. This technique allows for a better understanding of CSF dynamics in small laboratory animals.
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Affiliation(s)
- Yusuke Tomita
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.T.)
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba 286-8520, Japan
| | - Fumiko Seki
- Department of Physiology, Keio University School of Medicine, Tokyo 160-8582, Japan
- Bioimaging Center, Central Institute for Experimental Medicine and Life Science, Kawasaki 210-0821, Kanagawa, Japan
| | - Yuji Komaki
- Department of Physiology, Keio University School of Medicine, Tokyo 160-8582, Japan
- Bioimaging Center, Central Institute for Experimental Medicine and Life Science, Kawasaki 210-0821, Kanagawa, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.T.)
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.T.)
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Wolf K, Volz F, Lützen N, Mast H, Reisert M, Rahal AE, Fung C, Shah MJ, Beck J, Urbach H. Non-invasive biomarkers for spontaneous intracranial hypotension (SIH) through phase-contrast MRI. J Neurol 2024; 271:4336-4347. [PMID: 38643444 PMCID: PMC11233306 DOI: 10.1007/s00415-024-12365-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND AND OBJECTIVE Spontaneous intracranial hypotension (SIH) is an underdiagnosed disease. To depict the accurate diagnosis can be demanding; especially the detection of CSF-venous fistulas poses many challenges. Potential dynamic biomarkers have been identified through non-invasive phase-contrast MRI in a limited subset of SIH patients with evidence of spinal longitudinal extradural collection. This study aimed to explore these biomarkers related to spinal cord motion and CSF velocities in a broader SIH cohort. METHODS A retrospective, monocentric pooled-data analysis was conducted of patients suspected to suffer from SIH who underwent phase-contrast MRI for spinal cord and CSF velocity measurements at segment C2/C3 referred to a tertiary center between February 2022 and June 2023. Velocity ranges (mm/s), total displacement (mm), and further derivatives were assessed and compared to data from the database of 70 healthy controls. RESULTS In 117 patients, a leak was located (54% ventral leak, 20% lateral leak, 20% CSF-venous fistulas, 6% sacral leaks). SIH patients showed larger spinal cord and CSF velocities than healthy controls: e.g., velocity range 7.6 ± 3 mm/s vs. 5.6 ± 1.4 mm/s, 56 ± 21 mm/s vs. 42 ± 10 mm/s, p < 0.001, respectively. Patients with lateral leaks and CSF-venous fistulas exhibited an exceptionally heightened level of spinal cord motion (e.g., velocity range 8.4 ± 3.3 mm/s; 8.2 ± 3.1 mm/s vs. 5.6 ± 1.4 mm/s, p < 0.001, respectively). CONCLUSION Phase-contrast MRI might become a valuable tool for SIH diagnosis, especially in patients with CSF-venous fistulas without evidence of spinal extradural fluid collection.
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Affiliation(s)
- Katharina Wolf
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Florian Volz
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hansjoerg Mast
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Department of Radiology, Medical Physics, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
- Department of Neurosurgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Mukesch J Shah
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Sahoo P, Kollmeier JM, Wenkel N, Badura S, Gärtner J, Frahm J, Dreha-Kulaczewski S. CSF and venous blood flow from childhood to adulthood studied by real-time phase-contrast MRI. Childs Nerv Syst 2024; 40:1377-1388. [PMID: 38206441 PMCID: PMC11026278 DOI: 10.1007/s00381-024-06275-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE In vivo measurements of CSF and venous flow using real-time phase-contrast (RT-PC) MRI facilitate new insights into the dynamics and physiology of both fluid systems. In clinical practice, however, use of RT-PC MRI is still limited. Because many forms of hydrocephalus manifest in infancy and childhood, it is a prerequisite to investigate normal flow parameters during this period to assess pathologies of CSF circulation. This study aims to establish reference values of CSF and venous flow in healthy subjects using RT-PC MRI and to determine their age dependency. METHODS RT-PC MRI was performed in 44 healthy volunteers (20 females, age 5-40 years). CSF flow was quantified at the aqueduct (Aqd), cervical (C3) and lumbar (L3) spinal levels. Venous flow measurements comprised epidural veins, internal jugular veins and inferior vena cava. Parameters analyzed were peak velocity, net flow, pulsatility, and area of region of interest (ROI). STATISTICAL TESTS linear regression, student's t-test and analysis of variance (ANOVA). RESULTS In adults volunteers, no significant changes in flow parameters were observed. In contrast, pediatric subjects exhibited a significant age-dependent decrease of CSF net flow and pulsatility in Aqd, C3 and L3. Several venous flow parameters decreased significantly over age at C3 and changed more variably at L3. CONCLUSION Flow parameters varies depending on anatomical location and age. We established changes of brain and spinal fluid dynamics over an age range from 5-40 years. The application of RT-PC MRI in clinical care may improve our understanding of CSF flow pathology in individual patients.
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Affiliation(s)
- Prativa Sahoo
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany.
| | - Jost M Kollmeier
- Biomedical NMR, Max Planck Institute for Multidisciplinary Sciences, Göttingen, Germany
| | - Nora Wenkel
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany
| | - Simon Badura
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany
| | - Jutta Gärtner
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany
| | - Jens Frahm
- Biomedical NMR, Max Planck Institute for Multidisciplinary Sciences, Göttingen, Germany
| | - Steffi Dreha-Kulaczewski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany.
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Berman G, Mollan SP. The Pressure of Headache at the United Kingdom CSF Disorders Day 2023. Neuroophthalmology 2024; 48:204-209. [PMID: 38756340 PMCID: PMC11095568 DOI: 10.1080/01658107.2023.2290539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/01/2023] [Accepted: 11/18/2023] [Indexed: 05/18/2024] Open
Abstract
Headache in intracranial disorders drives significant disability in our patients. Management principles for secondary headaches require a multidisciplinary approach with expertise from the neurological, neuro-ophthalmological, neuroradiological, and neurosurgical specialities. The Pressure of Headache was the theme of the annual United Kingdom CSF Disorders Day and saw speakers and panellists from Australia, Europe, and the United States. Among the topics presented were the newest concepts underpinning idiopathic intracranial hypertension management and spontaneous intracranial hypotension. Advances in our knowledge of cerebrospinal fluid secretion and the visual snow syndrome debate were particular highlights. This review provides a summary of the research on headache disorders that overlap the neuro-ophthalmological axis of care for patients.
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Affiliation(s)
- Gabriele Berman
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P. Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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