1
|
Petutschnigg T, Häni L, Goldberg J, Dobrocky T, Piechowiak EI, Raabe A, Jesse CM, Schär RT. Microsurgical Repair of Ventral Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension: Efficacy and Safety of Patch-Sealing Versus Suturing. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01274. [PMID: 39132996 DOI: 10.1227/ons.0000000000001310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 06/25/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with spontaneous intracranial hypotension (SIH), microsurgical repair is recommended in Type 1 (ventral) dural leaks, when conservative measures fail. However, there is lacking consensus on the optimal surgical technique for permanent and safe closure of ventral leaks. METHODS We performed a retrospective analysis of surgically treated SIH patients with Type 1 leaks at our institution between 2013 and 2023. Patients were analyzed according to the type of surgical technique: (1) Microsurgical suture vs (2) extradural and intradural patching (sealing technique). End points were resolution of spinal longitudinal epidural cerebrospinal fluid collection (SLEC), change in brain SIH-Score (Bern-Score), headache resolution after 3 months, surgery time, complications, and reoperation rates. RESULTS In total, 85 (66% women) patients with consecutive SIH (mean age 47 ± 11 years) underwent transdural microsurgical repair. The leak was sutured in 53 (62%) patients (suture group) and patch-sealed in 32 (38%) patients (sealing group). We found no significant difference in the rates of residual SLEC and resolution of headache between suture and sealing groups (13% vs 22%, P = .238 and 89% vs 94%, P = .508). No changes were found in the postoperative Bern-Score between suture and sealing groups (1.4 [±1.6] vs 1.7 [±2.1] P = 1). Mean surgery time was significantly shorter in the sealing group than in the suture group (139 ± 48 vs 169 ± 51 minutes; P = .007). Ten patients of the suture and 3 of the sealing group had a complication (23% vs 9%, P = .212), whereas 6 patients of the suture and 2 patients of the sealing group required reoperation (11% vs 6%, P = .438). CONCLUSION Microsurgical suturing and patch-sealing of ventral dural leaks in patients with SIH are equally effective. Sealing alone is a significantly faster technique, requiring less spinal cord manipulation and may therefore minimize the risk of surgical complications.
Collapse
Affiliation(s)
- Thomas Petutschnigg
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - C Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| |
Collapse
|
2
|
Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
Collapse
Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
| |
Collapse
|
3
|
Callen AL, Pisani Petrucci SL, Lennarson P, Birlea M, MacKenzie J, Buchanan AJ. Perspectives from the Inaugural "Spinal CSF Leak: Bridging the Gap" Conference: A Convergence of Clinical and Patient Expertise. AJNR Am J Neuroradiol 2024; 45:841-849. [PMID: 38697790 DOI: 10.3174/ajnr.a8181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/18/2023] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND PURPOSE The inaugural "Spinal CSF Leak: Bridging the Gap" Conference was organized to address the complexities of diagnosing and treating spinal CSF leaks. This event aimed to converge the perspectives of clinicians, researchers, and patients with a patient-centered focus to explore the intricacies of spinal CSF leaks across 3 main domains: diagnosis, treatment, and aftercare. MATERIALS AND METHODS Physician and patient speakers were invited to discuss the varied clinical presentations and diagnostic challenges of spinal CSF leaks, which often lead to misdiagnosis or delayed treatment. Patient narratives were interwoven with discussions on advanced radiologic techniques and clinical assessments. Treatment-focused sessions highlighted patient experiences with various therapeutic options, including epidural blood patches, surgical interventions, and percutaneous and endovascular therapies. The intricacies of immediate and long-term postprocedural management were explored. RESULTS Key outcomes from the conference included the recognition of the need for increased access to specialized CSF leak care for patients and heightened awareness among health care providers, especially for atypical symptoms and presentations. Discussions underscored the variability in individual treatment responses and the necessity for personalized diagnostic and treatment algorithms. Postprocedural challenges such as managing incomplete symptom relief and rebound intracranial hypertension were also addressed, emphasizing the need for effective patient monitoring and follow-up care infrastructures. CONCLUSIONS The conference highlighted the need for adaptable diagnostic protocols, collaborative multidisciplinary care, and enhanced patient support. These elements are vital for improving the recognition, diagnosis, and management of spinal CSF leaks, thereby optimizing patient outcomes and quality of life. The event established a foundation for future advancements in spinal CSF leak management, advocating for a patient-centered model that harmonizes procedural expertise with an in-depth understanding of patient experiences.
Collapse
Affiliation(s)
- Andrew L Callen
- From the Department of Radiology (A.L.C., S.P.P.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samantha L Pisani Petrucci
- From the Department of Radiology (A.L.C., S.P.P.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Peter Lennarson
- Department of Neurosurgery (P.L.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Marius Birlea
- Department of Neurology (M.B.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | |
Collapse
|
4
|
Zander C, Wolf K, El Rahal A, Volz F, Beck J, Urbach H, Lützen N. Spontaneous intracranial hypotension - a spinal disease. ROFO-FORTSCHR RONTG 2024. [PMID: 38968964 DOI: 10.1055/a-2318-8994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Spontaneous intracranial hypotension (SIH) remains an underdiagnosed condition despite increasing awareness due to recent scientific advances. Diagnosis can be delayed by the broad clinical presentation and imaging pitfalls. This results in a high degree of physical impairment for patients, including social and psychological sequelae as well as long-term damage in the case of delayed diagnosis and treatment.The study is based on a selective literature search on PubMed including articles from 1990 to 2023 and the authors' clinical experience from working in a CSF center.SIH mostly affects middle-aged women, with the primary symptom being position-dependent orthostatic headache. In addition, there is a broad spectrum of possible symptoms that can overlap with other clinical conditions and therefore complicate the diagnosis. The causative spinal CSF loss can be divided into three main types: ventral (type 1) or lateral (type 2) dural leak and CSF-venous fistula (type 3). The diagnosis can be made using a two-stage workup. As a first step, noninvasive MRI of the head and spine provides indicators of the presence of SIH. The second step using focused myelography can identify the exact location of the cerebrospinal fluid leak and enable targeted therapy (surgical or interventional). Intrathecal pressure measurement or intrathecal injection of gadolinium is no longer necessary for primary diagnosis. Serious complications in the course of the disease can include space-occupying subdural hematomas, superficial siderosis, and symptoms of brain sagging, which can lead to misinterpretations. Treatment consists of closing the dural leak or the cerebrospinal fluid fistula. Despite successful treatment, a relapse can occur, which highlights the importance of follow-up MRI examinations and emphasizes the chronic nature of the disease. This paper provides an overview of the diagnostic workup of patients with suspected SIH and new developments in imaging and therapy. · SIH is an underdiagnosed condition with a wide range of possible symptoms.. · The first diagnostic step using MRI provides indications of the presence of SIH.. · The second diagnostic step using (dynamic) myelography can identify the CSF leak.. · Collaboration with a CSF center is advisable for further diagnosis and treatment.. · Prompt detection and treatment of SIH improves the outcome.. · Zander C, Wolf K, El Rahal A et al. Spontaneous intracranial hypotension - a spinal disease. Fortschr Röntgenstr 2024; DOI 10.1055/a-2318-8994.
Collapse
Affiliation(s)
- Charlotte Zander
- Dept. of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
| | - Katharina Wolf
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Amir El Rahal
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Florian Volz
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Horst Urbach
- Dept. of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
| | - Niklas Lützen
- Dept. of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
| |
Collapse
|
5
|
Volz F, El Rahal A, Fung C, Shah M, Lützen N, Urbach H, Beck J, Wolf K. Don't delay, but don't despair: symptom duration, comorbidity and outcome after closure of spinal cerebrospinal fluid leaks. J Neurol 2024; 271:2776-2786. [PMID: 38409537 PMCID: PMC11055789 DOI: 10.1007/s00415-024-12242-2] [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: 12/20/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Microsurgical sealing of spinal cerebrospinal fluid (CSF) leaks is a viable treatment option in spontaneous intracranial hypotension (SIH). Several factors may influence the outcome, with symptom duration probably the most modifiable variable. METHODS Patients with closure of spinal CSF leaks between September 2020 and March 2023 and a follow-up period of 6 months were included in this retrospective single-center study. Pre- and postoperative scores for impact of headaches (Headache Impact Test, HIT-6) and quality of life (QoL, EQ-5D-5L) were systematically collected. Multiple regression modelling and subgroup analyses for different symptom durations and comorbidities were performed for these outcomes. RESULTS One hundred patients (61% female, median age 43.5 years) were included. Six months postoperatively, there was significant improvement in headache impact (HIT-6: 66 (IQR 62-69) to 52 (IQR 40-61, p < 0.001) and QoL (EQ-5D-5L VAS: 40 (IQR 30-60) to 79 (IQR 60-90); EQ-5D-5L Index: 0.67 (IQR 0.35-0.8) to 0.91 (IQR 0.8-0.94, p < 0.001, respectively). Subgroup analysis for a symptom duration above (74%) and below 90 days (26%) and comorbidity, as well as multiple regression analysis, revealed a trend in favor of early treatment and lower comorbidity. However, even after a prolonged symptom duration, improvements were significant. CONCLUSION As patients with shorter symptom duration show a trend for a better outcome, our results promote a timely diagnosis and treatment in SIH patients. However, a significant postoperative improvement can still be expected even after a prolonged symptom duration.
Collapse
Affiliation(s)
- Florian Volz
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
- Department of Neurosurgery, Lindenhofspital, Bern, Switzerland
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| |
Collapse
|
6
|
Kapan A, Waldhör T, Schiffler T, Beck J, Wöber C. Health-related quality of life, work ability and disability among individuals with persistent post-dural puncture headache. J Headache Pain 2024; 25:64. [PMID: 38658862 PMCID: PMC11040840 DOI: 10.1186/s10194-024-01765-8] [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] [Received: 02/26/2024] [Accepted: 04/04/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects. METHODS We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21). RESULTS A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%. CONCLUSION This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.
Collapse
Affiliation(s)
- Ali Kapan
- Center for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria.
| | - Thomas Waldhör
- Center for Public Health, Department of Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Tobias Schiffler
- Center for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria
| | - Jürgen Beck
- Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Christian Wöber
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Cagnazzo F, Ducros A, Risi G, Charif M, Corti L, Rapido F, Le Bars E, Lonjon N, Costalat V. Safety and efficacy of transvenous embolization of cerebrospinal fluid-venous fistula in patients with spontaneous intracranial hypotension. Interv Neuroradiol 2024:15910199241247698. [PMID: 38651327 DOI: 10.1177/15910199241247698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Transvenous embolization is a recent treatment strategy for cerebrospinal fluid-venous fistulas (CSFVF), which are associated with spontaneous intracranial hypotension (SIH). METHODS Participants were selected from a prospective database on patients with CSFVF that received transvenous Onyx embolization. All patients underwent a brain magnetic resonance imaging (MRI) before and after embolization with MRI follow-up performed at least 3 months after treatment. Clinical and MRI results after treatment were described. RESULTS Twenty-one consecutive patients (median age 63 years, IQR = 58-71; females: 15/21 = 71.5%) with 30 CSFVF were included. Most lesions were situated between T9 and L1 (19/30 = 63%), 70% were right-sided, and 38% of the patients had multiples fistulas. Embolization was successful in all cases. The mean MRI SIH score before and after treatment was 6 (±2.5) and 1.4 (±1.6), respectively (p < 0.0001). Twenty patients (90%) experienced improvement of their initial condition, of which 67% reported complete clinical recovery. The mean HIT-6 score decreased from 67 (±15) to 38 (±9) (p < 0.0001), the mean amount of monthly headache days from 23.5 (±10) and 3.2 (±6.6) (p < 0.0001), the visual assessment scale (VAS) for headache severity from 8 (±1.9) to 1.2 (±2) (p < 0.0001), and the mean VAS for perception quality of life improved from 2.6 (±2.5) to 8.6 (±1.8) (p < 0.0001). There were no major complications. The suspected rebound headache rate after treatment was 33%. CONCLUSION Transvenous embolization of CSFVF allowed high rates of clinical improvement with no morbidity related to the treatment.
Collapse
Affiliation(s)
- Federico Cagnazzo
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Anne Ducros
- Neurorology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Gaetano Risi
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Mahmoud Charif
- Neurorology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Lucas Corti
- Neurorology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Francesca Rapido
- Anesthesiology and Critical Care Medicine, Montpellier University Hospital, Gui de Chauliac Montpellier, France
| | - Emmanuelle Le Bars
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Nicolas Lonjon
- Anesthesiology and Critical Care Medicine, Montpellier University Hospital, Gui de Chauliac Montpellier, France
| | - Vincent Costalat
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| |
Collapse
|
8
|
Cheema S, Mehta D, Qureshi A, Sayal P, Kamourieh S, Davagnanam I, Matharu M. Spontaneous intracranial hypotension. Pract Neurol 2024; 24:98-105. [PMID: 38135500 PMCID: PMC10958270 DOI: 10.1136/pn-2023-003986] [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] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is a highly disabling but treatable secondary cause of headache. Recent progress in neuroradiological techniques has catalysed understanding of its pathophysiological basis and clinical diagnosis, and facilitated the development of more effective investigation and treatment methods. A UK-based specialist interest group recently produced the first multidisciplinary consensus guideline for the diagnosis and treatment of SIH. Here, we summarise a practical approach to its clinical and radiological diagnosis, symptomatic and non-targeted interventional treatment, radiological identification of leak site and targeted treatment of the leak once it has been localised.
Collapse
Affiliation(s)
- Sanjay Cheema
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Dwij Mehta
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Ayman Qureshi
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Parag Sayal
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Salwa Kamourieh
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Indran Davagnanam
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Manjit Matharu
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|
9
|
El Rahal A, Haupt B, Fung C, Cipriani D, Häni L, Lützen N, Dobrocky T, Piechowiak E, Schnell O, Raabe A, Wolf K, Urbach H, Kraus LM, Volz F, Beck J. Surgical closure of spinal cerebrospinal fluid leaks improves symptoms in patients with superficial siderosis. Eur J Neurol 2024; 31:e16122. [PMID: 38015455 PMCID: PMC11235863 DOI: 10.1111/ene.16122] [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] [Received: 05/04/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND PURPOSE Spinal cerebrospinal fluid (CSF) leaks may cause a myriad of symptoms, most common being orthostatic headache. In addition, ventral spinal CSF leaks are a possible etiology of superficial siderosis (SS), a rare condition characterized by hemosiderin deposits in the central nervous system (CNS). The classical presentation of SS involves ataxia, bilateral hearing loss, and myelopathy. Unfortunately, treatment options are scarce. This study was undertaken to evaluate whether microsurgical closure of CSF leaks can prevent further clinical deterioration or improve symptoms of SS. METHODS This cohort study was conducted using data from a prospectively maintained database in two large spontaneous intracranial hypotension (SIH) referral centers in Germany and Switzerland of patients who meet the modified International Classification of Headache Disorders, 3rd edition criteria for SIH. Patients with spinal CSF leaks were screened for the presence of idiopathic infratentorial symmetric SS of the CNS. RESULTS Twelve patients were included. The median latency between the onset of orthostatic headaches and symptoms attributed to SS was 9.5 years. After surgical closure of the underlying spinal CSF leak, symptoms attributed to SS improved in seven patients and remained stable in three. Patients who presented within 1 year after the onset of SS symptoms improved, but those who presented in 8-12 years did not improve. We could show a significant association between patients with spinal longitudinal extrathecal collections and SS. CONCLUSIONS Long-standing untreated ventral spinal CSF leaks can lead to SS of the CNS, and microsurgical sealing of spinal CSF leaks might stop progression and improve symptoms in patients with SS in a time-dependent manner.
Collapse
Affiliation(s)
- Amir El Rahal
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
- Department of Neurosurgery, Faculty of Medicine of GenevaGeneva University HospitalGenevaSwitzerland
| | - Benedikt Haupt
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| | - Christian Fung
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| | - Debora Cipriani
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| | - Levin Häni
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Niklas Lützen
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center FreiburgFreiburgGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Eike Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Oliver Schnell
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Katharina Wolf
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| | - Horst Urbach
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center FreiburgFreiburgGermany
| | - Luisa Mona Kraus
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| | - Florian Volz
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| | - Jürgen Beck
- Department of NeurosurgeryUniversity Medical Center FreiburgFreiburgGermany
| |
Collapse
|
10
|
Häni L, Fung C, El Rahal A, Volz F, Kraus LM, Schnell O, Ferrarese R, Erny D, Schwabenland M, Urbach H, Lützen N, Beck J. Distinct Pattern of Membrane Formation With Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension. Oper Neurosurg (Hagerstown) 2024; 26:71-77. [PMID: 37747369 PMCID: PMC10688773 DOI: 10.1227/ons.0000000000000914] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/18/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To systematically describe pertinent, intraoperative anatomic findings encountered when approaching spinal cerebrospinal fluid (CSF) leaks and CSF-venous fistulas in spontaneous intracranial hypotension (SIH). METHODS In a retrospective study, we included surgically treated patients suffering from SIH at our institution from April 2018 to March 2022. Anatomic, intraoperative data were extracted from operative notes and supplemented with data from surgical videos and images. Prominent anatomic features were compared among different types of CSF leaks. RESULTS The study cohort consists of 120 patients with a mean age of 45.2 years. We found four distinct patterns of spinal membranes specifically associated with different types of CSF leaks: (i) thick, dorsal membranes, which were hypervascular and may mimic the dura (pseudodura); (ii) thin, lateral membranes encapsulating a ventral epidural CSF compartment (confining the spinal longitudinal extradural CSF collection); (iii) ventral membranes constituting a transdural funnel-like CSF channel; and (iv) lateral membranes forming spinal cysts/meningeal diverticulae associated with lateral CSF leaks. The latter three types resemble a layer of arachnoid herniated through the dural defect. CONCLUSION We describe four distinct spinal (neo-)membranes in association with spinal CSF leaks. Formation of these membranes, or emergence by herniation of arachnoid through a dural defect, constitutes a specific pathoanatomic feature of patients with SIH and CSF leaks. Recognition of these membranes is of paramount importance for diagnosis and treatment of patients with spinal CSF leaks.
Collapse
Affiliation(s)
- Levin Häni
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Christian Fung
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
- Faculty of Medicine of Geneva, Geneva, Switzerland;
| | - Florian Volz
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Luisa Mona Kraus
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Roberto Ferrarese
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Daniel Erny
- Institute of Neuropathology, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Marius Schwabenland
- Institute of Neuropathology, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| | - Horst Urbach
- Department of Neuroradiology, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany;
| |
Collapse
|
11
|
Cahal M, Roth J, Ungar OJ, Brinjikji W. Fluctuating hearing loss secondary to spontaneous intracranial hypotension: A case report and review of the literature. Interv Neuroradiol 2023:15910199231221863. [PMID: 38146166 DOI: 10.1177/15910199231221863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE Fluctuating sensorineural hearing loss (SNHL) has multiple etiologies, most commonly Ménière's disease (MD), recurrent sudden SNHL, and autoimmune inner ear disorders. Fluctuating SNHL has rarely been described as a symptom of spontaneous intracranial hypotension (SIH). PATIENT A 39-year-old previously healthy female presented with "Ménière's like" symptoms responsive to steroid treatment, which worsened during the day and improved in the supine position. Conservative treatment for MD consisting of low salt and caffeine diet and betahistine medication yielded no improvement. Secondary revision of brain imaging scans showed signs indicative of SIH, and a spinal cerebrospinal fluid leak was ultimately found and treated by a novel technique of transvenous fistula embolization by means of Onyx® glue, leading to gradual clinical improvement and near-complete resolution of symptoms. CONCLUSION SIH should be considered as part of the differential diagnosis of fluctuating SNHL. Clinical and radiological features should be known and sought. We suspect that early diagnosis and treatment can lead to cure and prevent permanent auditory damage.
Collapse
Affiliation(s)
- Michal Cahal
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | |
Collapse
|
12
|
Ellens NR, Schartz D, Ismail R, Kessler A, Ellika S, Akkipeddi SMK, Rahmani R, Bender MT. Efficacy of transvenous embolization of CSF-venous fistula in spontaneous intracranial hypotension: Case-series. Interv Neuroradiol 2023:15910199231221449. [PMID: 38130106 DOI: 10.1177/15910199231221449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension is a debilitating neurological condition which can be caused by a cerebrospinal fluid-venous fistula. Transvenous embolization is a promising technique to provide minimally invasive yet durable treatment. METHODS A retrospective single-center case series was performed on all patients who underwent transvenous embolization of a cerebrospinal fluid (CSF)-venous fistula. Clinical and radiographic parameters, including Bern score, were reported preoperatively and at 3-month follow-up. RESULTS Six patients underwent embolization of a CSF-venous fistula. All fistulae were located in the thoracic spine and technical success was achieved in all cases. Three patients had symptom resolution, two had significant improvement, and one had stable symptoms on follow-up. The mean Bern score was 6.83 (SD = 1.47) preoperatively and 1.83 (SD = 1.64) postoperatively with a mean improvement in Bern score of 5.0 (SD = 1.9, p = 0.0013). CONCLUSIONS CSF-venous fistulas are an increasingly recognized clinical entity which may be treated with transvenous embolization. This case series serves to further validate this technique and suggests it can be performed with similar outcomes in lower volume centers.
Collapse
Affiliation(s)
- Nathaniel R Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Shehenaz Ellika
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
13
|
Hong P, Kapadia A, Lai C, Kingston W, Meng H. Timeliness to definitive treatment to avoid severe neurologic complications associated with spontaneous intracranial hypotension. Can J Anaesth 2023; 70:1854-1856. [PMID: 37594663 DOI: 10.1007/s12630-023-02554-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 08/19/2023] Open
Affiliation(s)
- Patrick Hong
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Anish Kapadia
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Carolyn Lai
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - William Kingston
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Howard Meng
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| |
Collapse
|
14
|
Callen AL, Carlton Jones L, Timpone VM, Pattee J, Scoffings DJ, Butteriss D, Huynh T, Shen PY, Mamlouk MD. Factors Predictive of Treatment Success in CT-Guided Fibrin Occlusion of CSF-Venous Fistulas: A Multicenter Retrospective Cross-Sectional Study. AJNR Am J Neuroradiol 2023; 44:1332-1338. [PMID: 37798111 PMCID: PMC10631531 DOI: 10.3174/ajnr.a8005] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/27/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND PURPOSE CSF-to-venous fistulas contribute to spontaneous intracranial hypotension. CT-guided fibrin occlusion has been described as a minimally invasive treatment strategy; however, its reproducibility across different institutions remains unclear. This multi-institution study evaluated the clinical and radiologic outcomes of CT-guided fibrin occlusion, hypothesizing a correlation among cure rates, fibrin injectate spread, and drainage patterns. MATERIALS AND METHODS A retrospective evaluation was conducted on CT-guided fibrin glue treatment in patients with CSF-to-venous fistulas from 6 US and UK institutions from 2020 to 2023. Patient information, procedural characteristics, and injectate spread and drainage patterns were examined. Clinical improvement assessed through medical records served as the primary outcome. RESULTS Of 119 patients at a mean follow-up of 5.0 months, fibrin occlusion resulted in complete clinical improvement in 59.7%, partial improvement in 34.5%, and no improvement in 5.9% of patients. Complications were reported in 4% of cases. Significant associations were observed between clinical improvement and concordant injectate spread with the fistula drainage pattern (P = .0089) and pretreatment symptom duration (P < .001). No associations were found between clinical improvement and cyst puncture, intravascular extension, rebound headache, body mass index, age, or number of treatment attempts. CONCLUSIONS Fibrin occlusion performed across various institutions shows cure when associated with injectate spread matching the CVF drainage pattern and shorter pretreatment symptom duration, emphasizing the importance of accurate injectate placement and early intervention.
Collapse
Affiliation(s)
- Andrew L Callen
- From the Department of Radiology (A.L.C., V.M.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lalani Carlton Jones
- Imaging Department (L.C.J.), Guys and St Thomas's and Kings College Hospital Foundation Trusts, London, UK
| | - Vincent M Timpone
- From the Department of Radiology (A.L.C., V.M.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jack Pattee
- Department of Biostatistics and Informatics (J.P.), Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, Colorado
| | - Daniel J Scoffings
- Department of Radiology (D.J.S.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - David Butteriss
- Department of Neuroradiology (D.B.), Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - Thien Huynh
- Department of Radiology (T.H.), Division of Neuroradiology, Mayo Clinic, Jacksonville, Florida
| | - Peter Y Shen
- Department of Radiology (P.Y.S., M.D.M.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - Mark D Mamlouk
- Department of Radiology (P.Y.S., M.D.M.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
- Department of Radiology and Biomedical Imaging (M.D.M.), University of California, San Francisco, San Francisco, California
| |
Collapse
|
15
|
Volz F, Fung C, Wolf K, Lützen N, Urbach H, Kraus LM, Omer M, Beck J, El Rahal A. Recovery and long-term outcome after neurosurgical closure of spinal CSF leaks in patients with spontaneous intracranial hypotension. Cephalalgia 2023; 43:3331024231196808. [PMID: 37652456 DOI: 10.1177/03331024231195830] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid leak causes orthostatic headaches and impacts quality of life. Successful closure rates are often reported, whereas data on long-term outcome are still scarce. METHODS Between April 2020 and December 2022 surgically treated patients completed the Headache Impact Test-6 prior to surgery and at 14 days, three months, six months, and 12 months postoperatively. In addition to the Headache Impact Test-6 score, we extracted data related to orthostatic symptoms. RESULTS Eighty patients were included. Median Headache Impact Test-6 score preoperatively was 65 (IQR 61-69), indicating severe and disabling impact of headaches. At three months headache impact significantly improved to 49 (IQR 44-58) (p < 0.001) and remained stable up to 12 months (48, IQR 40-56), indicating little to no impact of headaches on quality of life. The need to lie down "always" or "very often" was reduced from 79% to 23% three months postoperatively (p < 0.001). CONCLUSIONS Surgical closure of spinal CSF leaks significantly improves the impact of headaches in the long term. At least three months should be expected for recovery. Despite permanent closure of the CSF-leak, a quarter of patients still have relevant long-term impairment, indicating the need for further research on its cause and possible treatment.
Collapse
Affiliation(s)
- Florian Volz
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Luisa Mona Kraus
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Mazin Omer
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| |
Collapse
|
16
|
Nowakowski E, Dayananda S, Morgan M, Jarvis O, Altamirano V, LaSorda KR, Krans E, Lim G. Obstetric pain management for pregnant women with opioid use disorder: A qualitative and quantitative comparison of patient and provider perspectives (QUEST study). Addiction 2023; 118:1093-1104. [PMID: 36662775 PMCID: PMC10175133 DOI: 10.1111/add.16134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 01/07/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM Patients with opioid use disorder (OUD) may experience inadequate pain management especially during childbirth. This study assessed and compared patient and provider perspectives on analgesia during and after delivery in women with OUD. DESIGN Prospective cohort, mixed method design including semi-structured interviews and structured surveys with pregnant or recently pregnant patients (n = 17) and provider (n = 15) groups. SETTING Prenatal clinics and hospital postpartum units. PARTICIPANTS Patients were pregnant women with OUD currently treated with methadone (n = 1) or buprenorphine (n = 16). Providers were obstetricians (n = 5), obstetric nurses (n = 5) and anesthesiologists (n = 5). MEASUREMENTS Validated questionnaires were completed by both groups; patient interviews were conducted during the third trimester and at 5 days post-delivery. Patient topics included pain management preferences, analgesia satisfaction and attitudes toward pain. Provider topics included labor and postpartum pain management perspectives. Interviews were independently coded and qualitatively analyzed for major themes. FINDINGS Five major themes emerged from patient interviews: (1) neuraxial blockade was endorsed for labor pain; (2) otherwise, limited pain control options were perceived; (3) no consensus around use of opioids for pain; (4) non-opioid options should be available; and (5) provider communication and health-care system issues act as barriers to adequate pain management. Provider perspective themes included the following: (1) unique challenges in pain management for patients with OUD; (2) confusion on how to plan for and make perinatal adjustments to medication for OUD; (3) discrepant views on use of opioids for pain management; (4) endorsement of non-pharmacological and non-opioid options; and (5) need for improved provider collaboration in developing pain management plans. CONCLUSIONS Patients with opioid use disorder and health-care providers prioritize pain management during and after childbirth, but have discrepant views on use of opioids and other pain management options. Inadequate care coordination and discrepancies in opinions need to be addressed both within care teams and between patients and providers. Clinicians would benefit from better evidence to guide clinical care of patients with OUD for patient-centered pain management.
Collapse
Affiliation(s)
- Emma Nowakowski
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sanjana Dayananda
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Madison Morgan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Olivia Jarvis
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Valeria Altamirano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kelsea R. LaSorda
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elizabeth Krans
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Innovation in Pain Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
17
|
Mehta D, Cheema S, Davagnanam I, Matharu M. Diagnosis and treatment evaluation in patients with spontaneous intracranial hypotension. Front Neurol 2023; 14:1145949. [PMID: 36970531 PMCID: PMC10036855 DOI: 10.3389/fneur.2023.1145949] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Spontaneous intracranial hypotension is characterized by an orthostatic headache and audiovestibular symptoms alongside a myriad of other non-specific symptoms. It is caused by an unregulated loss of cerebrospinal fluid at the spinal level. Indirect features of CSF leaks are seen on brain imaging as signs of intracranial hypotension and/or CSF hypovolaemia as well as a low opening pressure on lumbar puncture. Direct evidence of CSF leaks can frequently, but not invariably, be observed on spinal imaging. The condition is frequently misdiagnosed due to its vague symptoms and a lack of awareness of the condition amongst the non-neurological specialities. There is also a distinct lack of consensus on which of the many investigative and treatment options available to use when managing suspected CSF leaks. The aim of this article is to review the current literature on spontaneous intracranial hypotension and its clinical presentation, preferred investigation modalities, and most efficacious treatment options. By doing so, we hope to provide a framework on how to approach a patient with suspected spontaneous intracranial hypotension and help minimize diagnostic and treatment delays in order to improve clinical outcomes.
Collapse
Affiliation(s)
- Dwij Mehta
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- *Correspondence: Dwij Mehta
| | - Sanjay Cheema
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Indran Davagnanam
- Lysholm Department of Neuroradiology, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Manjit Matharu
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| |
Collapse
|
18
|
Piechowiak EI, Aeschimann B, Häni L, Kaesmacher J, Mordasini P, Jesse CM, Schankin CJ, Raabe A, Schär RT, Gralla J, Beck J, Dobrocky T. Epidural Blood Patching in Spontaneous Intracranial Hypotension-Do we Really Seal the Leak? Clin Neuroradiol 2023; 33:211-218. [PMID: 36028627 PMCID: PMC10014648 DOI: 10.1007/s00062-022-01205-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH). Follow-up after EBP primarily relies on clinical presentation and data demonstrating successful sealing of the underlying spinal cerebrospinal fluid (CSF) leak are lacking. Our aim was to evaluate the rate of successfully sealed spinal CSF leaks in SIH patients after non-targeted EBP. METHODS Patients with SIH and a confirmed spinal CSF leak who had been treated with non-targeted EBP were retrospectively analyzed. Primary outcome was persistence of CSF leak on spine MRI or intraoperatively. Secondary outcome was change in clinical symptoms after EBP. RESULTS In this study 51 SIH patients (mean age, 47 ± 13 years; 33/51, 65% female) treated with non-targeted EBP (mean, 1.3 EBPs per person; range, 1-4) were analyzed. Overall, 36/51 (71%) patients had a persistent spinal CSF leak after EBP on postinterventional imaging and/or intraoperatively. In a best-case scenario accounting for missing data, the success rate of sealing a spinal CSF leak with an EBP was 29%. Complete or substantial symptom improvement in the short term was reported in 45/51 (88%), and in the long term in 17/51 (33%) patients. CONCLUSION Non-targeted EBP is an effective symptomatic treatment providing short-term relief in a substantial number of SIH patients; however, successful sealing of the underlying spinal CSF leak by EBP is rare, which might explain the high rate of delayed symptom recurrence. The potentially irreversible and severe morbidity associated with long-standing intracranial hypotension supports permanent closure of the leak.
Collapse
Affiliation(s)
- Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland.
| | - Benjamin Aeschimann
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Christopher Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| |
Collapse
|
19
|
Evangelou P, Omrane MA, Thurow J, Mix M, Fung C, Lützen N, Blazhenets G, Urbach H, Beck J, Meyer PT. 68Ga-DOTA PET for Diagnosis of Spinal Cerebrospinal Fluid Leaks. J Nucl Med 2023; 64:430-436. [PMID: 35981896 DOI: 10.2967/jnumed.122.264059] [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] [Received: 02/23/2022] [Revised: 08/13/2022] [Accepted: 08/13/2022] [Indexed: 11/16/2022] Open
Abstract
Spontaneous intracranial hypotension due to spinal cerebrospinal fluid (CSF) leakage causes substantial disease burden. In many patients, the course is protracted and refractory to conservative treatment, requiring targeted therapy. We propose PET of the CSF space with 68Ga-DOTA as a state-of-the-art approach to radionuclide cisternography (RC) and validate its diagnostic value. Methods: This study is a retrospective analysis of patients with suspected intracranial hypotension due to spinal CSF leaks and who underwent whole-body PET/CT at 1, 3, and 5 h after intrathecal lumbar injection of 68Ga-DOTA. Two independent raters unaware of the clinical data analyzed all scans for direct and indirect RC signs of CSF leakage. Volume-of-interest analysis was performed to assess the biologic half-life of the tracer in the CSF space and the ratio of decay-corrected activity in the CSF space at 5 and 3 h (simplified marker of tracer clearance). Comprehensive stepwise neuroradiologic work-up served as a reference; additional validation was provided by surgical findings and follow-up. Results: Of 40 consecutive patients, 39 patients with a working diagnosis of intracranial hypotension due to a spinal CSF leak (spontaneous, n = 31; postintervention, n = 8) could be analyzed. A spinal CSF leak was verified by the neuroradiologic reference method in 18 of 39 patients. As the only direct and indirect diagnostic signs, extrathecal tracer accumulation at the cervicothoracic junction (67% sensitivity and 90% specificity) and lack of activity over the cerebral convexities (5 h; 94% sensitivity and 67% specificity) revealed a high diagnostic value for spinal CSF leaks. Their combination provided little improvement (71% sensitivity and 95% specificity). Additional quantitative analyses yielded no benefit (94% sensitivity and 53% specificity for biological half-life; 94% sensitivity and 58% specificity for the ratio of total radioactivity within the CSF space at 5 and 3 h). The location of direct signs (extrathecal tracer accumulation) did not correlate with verified sites of spinal CSF leakage. Conclusion: We propose CSF PET with 68Ga-DOTA as a novel, fast, and convenient approach to RC for verification but not localization of spinal CSF leaks with high sensitivity and specificity. CSF PET may fulfill an important gatekeeper function for stratifying patients toward escalation (ruling in) or deescalation (ruling out) of diagnostic and therapeutic measures. Further prospective studies are needed to validate the present results and determine the potential of the methods to reduce the burden to patients.
Collapse
Affiliation(s)
- Petros Evangelou
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mohamed Aymen Omrane
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Johannes Thurow
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Michael Mix
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Christian Fung
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ganna Blazhenets
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp T Meyer
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| |
Collapse
|
20
|
Halmagyi GM, Parker GD, Chen L, Welgampola MS, Watson JDG, Barnett MH, Todd MJ, El-Wahsh S, Rose V, Stoodley MA, Brennan JW. Progressive loss of hearing and balance in superficial siderosis due to occult spinal dural defects. Eur Arch Otorhinolaryngol 2023; 280:633-641. [PMID: 35841407 PMCID: PMC9849153 DOI: 10.1007/s00405-022-07523-3] [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: 02/20/2022] [Accepted: 06/20/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Superficial siderosis, a progressive, debilitating, neurological disease, often presents with bilateral impairment of auditory and vestibular function. We highlight that superficial siderosis is often due to a repairable spinal dural defect of the type that can also cause spontaneous intracranial hypotension. METHODS Retrospective chart review of five patients presenting with moderate to severe, progressive bilateral sensorineural hearing loss as well as vestibular loss. All patients had developed superficial siderosis from spinal dural defects: three after trauma, one after spinal surgery and one from a thoracic discogenic microspur. RESULTS The diagnosis was made late in all five patients; despite surgical repair in four, hearing and vestibular loss failed to improve. CONCLUSIONS In patients presenting with progressive bilateral sensorineural hearing loss, superficial siderosis should be considered as a possible cause. If these patients also have bilateral vestibular loss, cerebellar impairment and anosmia, then the diagnosis is likely and the inevitable disease progress might be halted by finding and repairing the spinal dural defect.
Collapse
Affiliation(s)
- G Michael Halmagyi
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia. .,Central Clinical School, University of Sydney, Sydney, Australia.
| | - Geoffrey D Parker
- Radiology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Luke Chen
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Miriam S Welgampola
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia
| | - John D G Watson
- Neurology Department, Sydney Adventist Hospital, Sydney, Australia
| | - Michael H Barnett
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.,Brain Mind Centre, University of Sydney, Sydney, Australia
| | - Michael J Todd
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Shadi El-Wahsh
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Victoria Rose
- Audiology Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Marcus A Stoodley
- Neurosurgery Department, Macquarie University Hospital, Sydney, Australia
| | - Jeffrey W Brennan
- Neurosurgery Department, Royal Prince Alfred Hospital, Sydney, Australia
| |
Collapse
|
21
|
Häni L, Fung C, Jesse CM, Schild C, Piechowiak EI, Dobrocky T, Raabe A, Beck J. Cerebrospinal fluid biomarkers of superficial siderosis in patients with spontaneous intracranial hypotension. Eur J Neurol 2023; 30:235-240. [PMID: 36209476 DOI: 10.1111/ene.15591] [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: 08/14/2022] [Accepted: 09/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension (SIH) is an important etiology of infratentorial superficial siderosis (iSS) of the central nervous system. However, the prevalence of iSS amongst patients with SIH is unknown and the imaging findings of iSS might represent a late stage of disease. The aim was to identify cerebrospinal fluid (CSF) biomarkers of iSS in patients with SIH. METHODS Consecutive patients evaluated for SIH at our institution between May 2017 and January 2019 were included. Lumbar CSF samples were analyzed for the presence of ferritin and bilirubin. Magnetic resonance imaging was assessed for the presence of iSS. RESULTS Twenty-four patients with SIH were included. CSF samples were positive for bilirubin in 2/19 (10.5%). CSF ferritin was elevated in 7/23 (30.4%). Signs of iSS on imaging were present in four patients (16.7%). All patients with imaging signs of iSS demonstrated elevated CSF ferritin. Ferritin level was significantly higher amongst patients demonstrating iSS compared to those without (median 45.0 vs. 11.0 μg/l; p = 0.003). Symptom duration was longer in patients with iSS than in patients without iSS (median 40 months vs. 9 months, p = 0.018). CONCLUSION Cerebrospinal fluid alterations indicative of iSS are prevalent amongst patients with SIH. It is speculated that a preclinical phase without symptoms or imaging signs but during which elevated biomarkers of the disease are apparent from CSF analysis might exist. It is suggested that measurement of CSF ferritin is incorporated in the work-up of patients with SIH to identify those at risk of developing iSS.
Collapse
Affiliation(s)
- Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Christopher Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christof Schild
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eike Immo Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| |
Collapse
|
22
|
Cheema S, Anderson J, Duncan C, Davagnanam I, Armstrong P, Redfern N, Ordman A, D’Antona L, Nissen J, Sayal P, Vaughan-Huxley E, Lagrata S, Iodice V, Snape-Burns J, Joy C, Matharu M. Survey of healthcare professionals’ knowledge, attitudes and practices regarding spontaneous intracranial hypotension. BMJ Neurol Open 2022; 4:e000347. [PMID: 36110926 PMCID: PMC9445790 DOI: 10.1136/bmjno-2022-000347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the knowledge, attitudes and practices of healthcare professionals regarding the diagnosis and management of spontaneous intracranial hypotension (SIH). Methods We performed a cross-sectional, web-based survey of multiple healthcare professional groups in the UK from June to August 2021. There were 227 respondents to the survey, including 62 general practitioners, 39 emergency medicine physicians, 38 neurologists, 35 radiologists, 20 neurosurgeons, 18 anaesthetists and 15 headache nurse specialists. The majority of the respondents were at the consultant level and all worked in the UK National Health Service. Results Few general practitioners or emergency medicine physicians had ever been involved in the care of a patient with SIH or received teaching about SIH. Only 3 of 62 (4.8%) general practitioners and 1 of 39 (2.5%) emergency medicine physicians were confident in recognising the symptoms of SIH. Most neurologists were confident in recognising SIH and performed MRI of the brain as a first-line investigation, although there was variability in the urgency of the request, whether contrast was given or MRI of the spine organised at the same time. Most said they never or rarely performed lumbar puncture for diagnosis of SIH. Most neuroradiologists, but few general radiologists, were confident in interpreting imaging of patients with suspected SIH. Lack of access to epidural blood patching, personnel able to perform myelography, and established management pathways were identified by many respondents as barriers to the treatment of SIH. Conclusions We have identified a lack of awareness of SIH among non-specialists, several barriers to optimal treatment of SIH and a variation in current management pathways. The results highlight the need for education of healthcare professionals about SIH and the development of clinical practice guidelines to enable delivery of optimal and equitable care for patients with SIH.
Collapse
Affiliation(s)
- Sanjay Cheema
- UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jane Anderson
- Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Indran Davagnanam
- UCL Queen Square Institute of Neurology, London, UK
- Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Paul Armstrong
- Neuroradiology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Nancy Redfern
- Anaesthetics, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Linda D’Antona
- UCL Queen Square Institute of Neurology, London, UK
- Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Justin Nissen
- Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Parag Sayal
- Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Susie Lagrata
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Clare Joy
- CSF Leak Association, Strathpeffer, UK
| | - Manjit Matharu
- UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|
23
|
The impact of spontaneous intracranial hypotension on social life and health-related quality of life. J Neurol 2022; 269:5466-5473. [PMID: 35701531 PMCID: PMC9467959 DOI: 10.1007/s00415-022-11207-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
Objective Spontaneous intracranial hypotension (SIH), which is often caused by a spinal cerebrospinal fluid leak, is an important cause of disabling headaches. Many patients report devastating changes in their quality of life because of their symptoms. This study aimed to evaluate the impact of SIH on patients’ social/ working life and health-related quality of life (HRQoL). Methods We included consecutive patients with proven SIH treated at our institution from January 2013 to May 2020. Patients were contacted and asked to complete the 15D questionnaire for the collection of HRQoL data and to provide additional information on their social life status. Results Of 112 patients, 79 (70.5%) returned the questionnaire and were included in the analysis. Of those, 69 were treated surgically (87.3%), and 10 were managed non-operatively (12.7%). Twenty-five (31.6%) patients reported a severe impact on their partnership, 32 (41.5%) reported a moderate or severe impact on their social life. Forty (54.8%) patients reported sick leave for more than 3 months. The mean 15D score was 0.890 (± 0.114) and significantly impaired compared to an age- and sex-matched general population (p = 0.001), despite treatment. Patients with residual SIH-symptoms (36, 45.6%) had significantly impaired HRQoL compared to those without any residual symptoms (41, 51.9%) (p < 0.001). Conclusion SIH had a notable impact on the patients’ social life and HRQoL. It caused long periods of incapacity for work, and is therefore, associated with high economic costs. Although all patients were appropriately treated, reduced HRQoL persisted after treatment, underlining the chronic character of this disease.
Collapse
|
24
|
Cheema S, Joy C, Pople J, Snape-Burns J, Trevarthen T, Matharu M. Patient experience of diagnosis and management of spontaneous intracranial hypotension: a cross-sectional online survey. BMJ Open 2022; 12:e057438. [PMID: 35058269 PMCID: PMC8783814 DOI: 10.1136/bmjopen-2021-057438] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To present the results of a survey of patients with spontaneous intracranial hypotension (SIH) secondary to spinal cerebrospinal fluid (CSF) leak, documenting the patient experience of its diagnosis and management as well as quantifying its impact on quality of life. DESIGN A cross-sectional anonymous online survey was designed in conjunction with the CSF Leak Association patient charity. The survey included questions on diagnosis, investigations and treatments received, as well as validated disability and quality of life questionnaires. PARTICIPANTS Sixty-four patients with a confirmed diagnosis of SIH who were receiving treatment within the UK were included in the analysis. The mean age was 42.8 years, 94% were female and 43 had ongoing symptoms of SIH. RESULTS Patients who presented to their general practitioner with symptoms of SIH were seen an average three times before being referred to a specialist, and in just under half of patients, the diagnosis was not made by the first specialist they saw. There was variability in which investigations were performed and how urgently they were organised. The mean EuroQol (EQ-5D-5L) Visual Analogue Scale score was 36.4/100 and median Headache Impact Test-6 score was 68/78 (very severe impact). More than half of the respondents reported that they had to amend work duties due to SIH, more than a quarter reported that they had lost their job and two-thirds reported that their condition had affected their financial health. Only 23.4% of patients felt that they had received enough help and advice to manage their pain due to SIH. CONCLUSIONS SIH is a highly disabling disorder, affecting multiple domains, including pain, mobility, activities of daily living, financial circumstances and employment. Diagnostic delay and misdiagnosis are common, and currently there is a lack of consistency in the investigation and management of SIH in the UK.
Collapse
Affiliation(s)
- Sanjay Cheema
- Headache and Facial Pain Group, UCL Queen Square Institute of Neurology, London, UK
| | - Clare Joy
- CSF Leak Association, Strathpeffer, Scotland, UK
| | - Jenny Pople
- CSF Leak Association, Strathpeffer, Scotland, UK
| | | | | | - Manjit Matharu
- Headache and Facial Pain Group, UCL Queen Square Institute of Neurology, London, UK
| |
Collapse
|
25
|
Zhang A, Song J, Czerwein JK. Brain Herniation Secondary to Cerebrospinal Fluid Leak Following Elective Lumbar Spine Surgery. Cureus 2021; 13:e20266. [PMID: 35004068 PMCID: PMC8735843 DOI: 10.7759/cureus.20266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 12/03/2022] Open
Abstract
Lumbar spine surgery can be complicated by perioperative cerebrospinal fluid (CSF) leak. However, development of brain herniation secondary to CSF leak following lumbar spine surgery has not been previously reported in the current literature. This case report describes a 48-year-old woman who, after a revision lumbar decompression and fusion, experienced CSF leak followed by development of brain herniation, which resulted in patient demise. The postoperative period was complicated by patient nonadherence to conservative management of CSF leak.
Collapse
|
26
|
Affiliation(s)
- Wouter I Schievink
- From the Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles
| |
Collapse
|