Intracranial hypertension syndrome as an unusual form of presentation of spinal subarachnoid haemorrhage and subdural haematoma

Research into the Physiology of Cerebrospinal Fluid Reaches a New Horizon: Intimate Exchange between Cerebrospinal Fluid and Interstitial Fluid May Contribute to Maintenance of Homeostasis in the Central Nervous System

Cerebrospinal fluid (CSF) plays an essential role in maintaining the homeostasis of the central nervous system. The functions of CSF include: (1) buoyancy of the brain, spinal cord, and nerves; (2) volume adjustment in the cranial cavity; (3) nutrient transport; (4) protein or peptide transport; (5) brain volume regulation through osmoregulation; (6) buffering effect against external forces; (7) signal transduction; (8) drug transport; (9) immune system control; (10) elimination of metabolites and unnecessary substances; and finally (11) cooling of heat generated by neural activity. For CSF to fully mediate these functions, fluid-like movement in the ventricles and subarachnoid space is necessary. Furthermore, the relationship between the behaviors of CSF and interstitial fluid in the brain and spinal cord is important. In this review, we will present classical studies on CSF circulation from its discovery over 2,000 years ago, and will subsequently introduce functions that were recently discovered such as CSF production and absorption, water molecule movement in the interstitial space, exchange between interstitial fluid and CSF, and drainage of CSF and interstitial fluid into both the venous and the lymphatic systems. Finally, we will summarize future challenges in research. This review includes articles published up to February 2016.

More than meets the eye? Redefining idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a disease of unknown etiology associated with increased intracranial pressure, predominantly affecting obese females of childbearing age. The history of IIH is quite unique, featuring only limited advancements in evidenced-based treatments, but boasting literally countless changes in nomenclature, proposed etiology, and conceptual approach. Despite its elusive pathogenesis, an evolution of our approach to IIH can be traced sequentially through identifiable periods. Contemporary research suggests that we are approaching a new phase in IIH, redefining it as a global neurologic syndrome with more far-reaching effects than previously realized.

Acute spontaneous spinal subdural haematoma presenting as paraplegia and complete recovery with non-operative treatment

Spontaneous spinal subdural haematoma (SSDH) with no underlying pathology is a very rare condition. Only 20 cases have been previously reported. It can be caused by abnormalities of coagulation, blood dyscrasia, or trauma, underlying neoplasm, and arteriovenous malformation. It occurs most commonly in the thoracic spine and presents with sudden back pain radiating to the arms, legs or trunk, and varying degrees of motor, sensory, and autonomic disturbances. Although the main approach to management is surgical decompression, conservative management is used as well. We report the case of a 57-year-old man who presented with sudden severe low back pain followed by rapid onset of complete paraplegia. Magnetic resonance imaging (MRI) revealed an anterior subdural haematoma from T9 to L1 with cord compression. Corticosteroid treatment was administered. The patient showed substantial clinical improvement after 7 days of bed rest and an intense rehabilitation programme. An MRI scan and a computed tomography angiogram did not reveal any underlying pathology to account for the subdural haematoma.

Cerebrospinal fluid outflow: an evolving perspective

Cerebrospinal fluid (CSF) serves numerous important functions in the central nervous system. Despite numerous reports characterizing CSF and its circulation in the subarachnoid space, our understanding of CSF outflow remains limited. Although initial work suggested that both arachnoid granulations and lymphatic capillaries shared in the role of CSF outflow, predominant work since then has focused on the arachnoid granulations. A growing body of recent evidence not only suggests the importance of both arachnoid granulations and lymphatic capillaries, but also additional contributions through transependymal passage likely share in the role of CSF outflow. Consideration of all mechanisms and pathways will help us to better understand the significance of CSF outflow, in health and disease. Here we review how the present concept of CSF outflow has evolved, including a historical review of significant findings and a discussion of the latest innovative developments.

Spinal subarachnoid hemorrhage complicating oral anticoagulant therapy

Spinal subarachnoid hemorrhage (SAH) is rare clinical entity possible owing to the diluting and fibrinolytic effects of cerebrospinal fluid (CSF). When it occurs, it is most commonly encountered in the thoracic segment of the subarachnoid space. We present a case of a 50-year-old man who sustained spinal SAH in the cervical and thoracic segments related to anticoagulant therapy. He progressed to significant neurological deficit since he was inoperable, an observation that supports the need for decompression surgery. We should be aware of potential hematomyelia should a patient on anticoagulant therapy develop neurological symptoms localized to the spinal cord. When available, magnetic resonance (MR) imaging is the modality of choice to diagnose and follow-up spinal SAH.

Spinal subdural haematoma: a study of three cases

AIMS

To define the clinical, computed tomography (CT) and magnetic resonance imaging (MRI) features and the role of MRI in the follow-up of spinal subdural haematoma (SSH), and to compare these findings with those of spinal epidural haematomas (SEH).

METHODS

We report three cases of SSH (two women, one male, age: 50-74 years). Two patients were on anticoagulant therapy; in the other case the SSH was spontaneous. All the patients were examined 1-3 days after the onset of the symptoms. All of them had CT, two had MRI and one had angiography. Two patients underwent surgery.

RESULTS

The haematoma was located in the thoracolumbar region (two) and in the thoracic region (one), extending from five (two) to 11 vertebral body levels (one). The haematomas were posteriorly located with lateral extension. The transverse shape differed with the level: biconvex, biloculated or circumferential. The haematomas were hyperdense on CT. On MRI, SSH yielded high signal on both T1 and T2. The integrity of the posterior fat pads, which was well shown on CT and MRI, and the visualization of the dura mater demonstrated the intradural location of these collections, making them easily distinguishable from spinal epidural haematoma. MRI provides better evaluation of the longitudinal extent. Our results are compared with those reported in the literature.

CONCLUSION

MRI is superior to CT for diagnosis and follow-up of SSH. Our findings and those reported in the literature show that the MR features of SSH are quite specific and allow differentiation from SEH.