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Lin PT, Hseu SS, Fuh JL, Lirng JF, Chen SP, Chen WT, Wang SJ, Wang YF. Sex differences in the clinical manifestations and treatment outcomes in a large cohort of spontaneous intracranial hypotension. Headache 2024. [PMID: 39221780 DOI: 10.1111/head.14816] [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: 01/20/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To determine sex differences in clinical profiles and treatment outcomes in patients with spontaneous intracranial hypotension. BACKGROUND Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether males and females should be managed differently. METHODS This was a cohort study of consecutive patients with spontaneous intracranial hypotension enrolled from a medical center. Medical records and imaging findings were reviewed. The outcome of treatment responses to epidural blood patches and risks of subdural hematoma were measured. RESULTS In total, 442 patients with spontaneous intracranial hypotension (165 males, 277 females) were included in the analysis. Males were more likely to have a delayed (>30 days) initial presentation than females (32.1% [53/165] vs. 19.9% [55/277], p = 0.004), and males were less likely to have nausea (55.8% [92/165] vs. 67.1% [186/277], p = 0.016), vomiting (43.0% [71/165] vs. 54.2% [150/277], p = 0.024), photophobia (9.7% [16/165] vs. 17.0% [47/277], p = 0.034), and tinnitus (26.7% [44/165] vs. 39.7% [110/277], p = 0.005) compared with females despite comparable radiologic findings. Among the 374 patients treated with epidural blood patches, males were more likely to be nonresponders to the first epidural blood patch (58.0% [80/138] vs. 39.0% [92/236], OR = 2.2, 95% CI = 1.4-3.3, p < 0.001). Males were at a higher risk of having subdural hematoma (29.7% [49/165] vs. 10.8% [30/277], OR = 3.5, 95% CI = 2.1-5.8, p < 0.001). Among patients with subdural hematoma, males had greater thickness (12.8 ± 4.3 vs. 8.1 ± 5.9 mm, p < 0.001) and were more likely to receive surgical drainage (55.1% [27/49] vs. 10.0% [3/30], OR = 11.0, 95% CI = 3.0-41.3, p < 0.001) than females. CONCLUSION In the present study, spontaneous intracranial hypotension in males was characterized by a delayed presentation, poorer response to the first epidural blood patch, and a higher risk of subdural hematoma. Caution should be exercised in the management of males with spontaneous intracranial hypotension. The generalizability of the findings needs to be further confirmed.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Shya Hseu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Ministry of Health and Welfare Keelung Hospital, Keelung, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Sousa G, Alves B, Cunha F, Magalhães J, Figueiredo E, Abreu L. Closing the Gap: A Case Report on a Blood Patch Solution for Cerebrospinal Fluid Leak. Cureus 2023; 15:e50784. [PMID: 38239555 PMCID: PMC10795794 DOI: 10.7759/cureus.50784] [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] [Accepted: 12/19/2023] [Indexed: 01/22/2024] Open
Abstract
Spontaneous intracranial hypotension is a condition resulting from cerebrospinal fluid leaks at the spinal level that disrupt the regulation of intracranial pressure. This disorder is an uncommon cause of debilitating headaches but can have variable clinical manifestations, which contributes to delayed diagnosis and potentially severe consequences. The standard treatment consists of conservative measures such as bed rest, hydration, and a pharmacological approach with paracetamol, caffeine, ergotamine, and dexamethasone. When conservative measures fail, an epidural blood patch is the gold standard treatment, where a small amount of blood is injected into the epidural space to form a clot to seal any existing leak. Recent studies showed a success rate of 64% without the need for further intervention. The authors report a case of a 55-year-old woman with a three-month history of daily severe headaches. Imaging exams showed subdural collections, suggesting the hypothesis of cerebrospinal fluid hypotension. After the failure of conservative measures, an epidural blood patch was performed with progressive clinical improvement. This case demonstrates the potential effectiveness of an epidural blood patch in the management of spontaneous intracranial hypotension and its complications, offering an encouraging option for those unresponsive to conservative measures. It also highlights the importance of a multidisciplinary approach involving neurologists and anesthesiologists.
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Affiliation(s)
- Guilherme Sousa
- Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, PRT
| | - Bárbara Alves
- Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, PRT
| | - Filipa Cunha
- Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, PRT
| | | | | | - Luís Abreu
- Neurology, Centro Hospitalar Tondela-Viseu, Viseu, PRT
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Hazama A, Awawdeh F, Braley A, Loree J, Swarnkar A, Chin LS, Krishnamurthy S. Recurrent Spontaneous Intracranial Hypotension (SIH) and the Durability of Repeat Epidural Blood Patch (EBP). Cureus 2023; 15:e41457. [PMID: 37546124 PMCID: PMC10404115 DOI: 10.7759/cureus.41457] [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] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Spontaneous intracranial hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) of the dural sac is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate the recent efficacy and outcomes of EBP for SIH at our institution. METHODS Twenty-three patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018 at the same institution. All patients underwent brain MRI with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBP was placed one or two vertebral levels below areas of suspected leak, while the patient was positioned in the lateral decubitus position. Patients were seen in the outpatient setting within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 months following clinical relief of symptoms. RESULTS 22/23 (95.7%) patients presented with complaints of orthostatic headache, and 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningeal enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had a subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, and 5/23 (21.7%) patients received further EBPs for persistent disease with all achieving relief after repeat EBP. 5/12 (41.7%) of patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient were 21.7 mL (median 20 mL, 7-40 mL) and 3.54 (median 1, 1-13) respectively. There was one complication from initial EBP (cervical dural tear requiring operative closure) treated with open surgical management successfully. In total, 18/23 (78.2%) patients are currently asymptomatic with regard to their SIH. The mean follow-up in this cohort was 2.6 years (median 1.8 years, 1.8 months-9.27 years). CONCLUSIONS EBP is a viable and effective option for the treatment of recurrent SIH caused by cerebrospinal fluid (CSF) leaks.
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Affiliation(s)
- Ali Hazama
- Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA
| | - Fakhri Awawdeh
- Neurological Surgery, Lake Erie College of Osteopathic Medicine, Elmira, USA
| | - Alexander Braley
- Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA
| | - John Loree
- General Surgery, Temple University Hospital, Philadelphia, USA
| | - Amar Swarnkar
- Neuroradiology, The State University of New York Upstate Medical University, Syracuse, USA
| | - Lawrence S Chin
- Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA
| | - Satish Krishnamurthy
- Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA
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Hassan D, Hassan HM, Rameen S. Comment on: Comparison of clinical characteristics with spontaneous intracranial hypotension complicated with subdural hematoma between surgical treatment and non-surgical treatment. Clin Neurol Neurosurg 2023; 229:107729. [PMID: 37121028 DOI: 10.1016/j.clineuro.2023.107729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 04/18/2023] [Indexed: 05/02/2023]
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Ozyigit A. Spontaneous intracranial hypotension complicated by unilateral subdural hematoma, coma, and the rare Kernohan's notch phenomenon. Clin Case Rep 2023; 11:e6899. [PMID: 36703772 PMCID: PMC9871412 DOI: 10.1002/ccr3.6899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 08/25/2022] [Accepted: 01/11/2023] [Indexed: 01/25/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a highly underdiagnosed condition with a wide range of manifestations. Although SIH has traditionally been viewed as having a benign disease course, recent evidence suggests otherwise. In this case report, we present a 71-year-old woman who was previously treated with a tapered dose of corticosteroids for an episode of SIH with behavioral manifestations. In this current report, we present her second episode which was complicated by a unilateral sub-acute subdural hematoma leading to loss of consciousness and coma. While the patient regained full consciousness and recovered considerably, she still suffers from ipsilateral hemiparesis as a result of Kernohan's notch phenomenon 2 years post-hospitalization. To the author's knowledge, this is the first case to involve persistent motor deficit after the resolution of SIH. We believe that surgical hematoma evacuation prior to addressing the cerebrospinal fluid leak may have contributed to aggregated downward displacement of the brain precipitating Kernohan's notch phenomenon.
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Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [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: 12/02/2022]
Abstract
INTRODUCTION Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed. AREAS COVERED The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes. EXPERT OPINION The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.
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Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Alomari MH, Shahin MM, Fishman SJ, Kerr CL, Smith ER, Eng W, Ruiz-Gutierrez M, Adams DM, Orbach DB, Chaudry G, Shaikh R, Chewning R, Alomari AI. Cerebrospinal fluid leak in epidural venous malformations and blue rubber bleb nevus syndrome. J Neurosurg Spine 2022; 37:439-445. [PMID: 35364593 DOI: 10.3171/2022.1.spine2138] [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: 01/08/2021] [Accepted: 01/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical manifestations of blue rubber bleb nevus syndrome (BRBNS) and multifocal venous malformation (MVM) vary depending on the location of the lesions. The aim of this study was to assess the risk of developing CSF leaks in patients with epidural venous malformations (VMs). METHODS The authors retrospectively investigated the relationship between the development of a CSF leak and the presence of epidural VMs. RESULTS Nine patients (5 females) had epidural VMs and presentation that was confirmatory or suggestive of a CSF leak: 4 had BRBNS, 4 had MVMs, and 1 had a solitary VM. Of 66 patients with BRBNS, clinical and imaging features of CSF leak were noted in 3 (4.5%) with epidural VMs at the age of 11-44 years. A fourth patient had suggestive symptoms without imaging confirmation. An epidural blood patch was ineffective in 2 patients, both with more than one source of leakage, requiring surgical repair or decompression. Symptomatic downward displacement of the cerebellar tonsils was noted in 3 patients with MVM and 1 with a solitary VM; 3 required surgical decompression. CONCLUSIONS These findings suggest an increased risk of CSF leak in patients with epidural VM, including BRBNS, MVMs, and solitary VMs. Awareness of the association between epidural VM and CSF leakage may facilitate earlier diagnosis and therapeutic intervention.
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Affiliation(s)
| | | | | | - Cindy L Kerr
- 1Division of Vascular and Interventional Radiology
| | | | - Whitney Eng
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melisa Ruiz-Gutierrez
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Denise M Adams
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Raja Shaikh
- 1Division of Vascular and Interventional Radiology
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Casanova A, Entz L, Weinmann S, Wanke I, Reisch R. Bilateral subdural hematoma caused by spontaneous intracranial hypotension originating from a discogenic microspur successfully treated with duraplasty: A case report. BRAIN AND SPINE 2022; 2:100879. [PMID: 36248145 PMCID: PMC9562247 DOI: 10.1016/j.bas.2022.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 11/25/2022]
Abstract
Introduction Discogenic microspurs are calcified outgrowths from the intervertebral disc which can perforate the dura, causing a leak of cerebrospinal fluid (CSF). Spontaneous leaks of the CSF present a recognized cause of spontaneous intracranial hypotension (SIH). Moreover, subdural hematomas (SDH) are a potentially severe complication of SIH. Research question We present a case of a bilateral subdural hematoma without orthostatic headaches caused by a discogenic microspur protruding from the T1-2 intervertebral disc. The microspur is conjectured to be the culprit of the leak by ventrally perforating the dura and catalyzing the causal chain leading to the formation of the subdural hemorrhage. Material and methods A 79-year woman noticed a progressive gait disturbance accompanied by a decline of short-term memory over several months without experiencing orthostatic headaches. Magnetic resonance imaging (MRI) showed extensive bilateral subdural fronto-parietal hematoma, signs of CSF hypotension (dilated venous compartments), and computed tomography (CT) myelography revealed a CSF leak originating at the T1-2 level. Results The leakage site was treated with microsurgical duraplasty leading to a regression of the symptoms and complete resolution of the subdural hematomas within five postoperative months. Discussion and conclusion Discogenic microspurs can perforate the dura causing a CSF leak, leading to spontaneous intracranial hypotension, finally resulting in a bilateral subdural hematoma. This constellation of symptoms does not necessarily induce orthostatic headaches and can be treated with microsurgical duraplasty. Discogenic microspur perforating the dura and inducing a liquor leak. Discogenic microspur leading to spontaneous intracranial hypotension. Discogenic microspur leading to bilateral subdural hematoma. Liquor leak treated by microsurgical duraplasty. Bilateral subdural hematoma retraction after microsurgical duraplasty.
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Affiliation(s)
- Andrea Casanova
- University of Zurich, Rämistrasse 71, 8006, Zurich, Switzerland
- Department of Emergency Medicine, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
- Corresponding author. University of Zurich, Rämistrasse 71, 8006, Zurich, Switzerland.
| | - László Entz
- Department of Neurosurgery, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
| | - Simon Weinmann
- Department of Emergency Medicine, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
| | - Isabel Wanke
- Department of Radiology, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
| | - Robert Reisch
- Department of Neurosurgery, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
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Liu N, Fei Y, He FF. Targeted Epidural Blood Patch Treatment for Refractory Spontaneous Intracranial Hypotension: A Case Report. J Neurol Surg Rep 2021; 82:e49-e52. [PMID: 34877247 PMCID: PMC8635819 DOI: 10.1055/s-0041-1740153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/24/2021] [Indexed: 11/07/2022] Open
Abstract
Purpose of Review
Spontaneous intracranial hypotension (SIH) is recognized far more commonly than before, and it is well known that SIH is sometimes complicated by chronic subdural hematoma (SDH). We reported a patient who was treated with epidural blood patch (EBP) five times for refractory SIH and SDH surgery.
Recent Findings
We experienced that targeted EBP was useful in refractory SIH, and also can be performed safely prior to drainage of the hematoma.
Summary
We report the case of SIH patient with a bilateral SDH who came to our hospital and was discharged 2 weeks later with no neurologic deficit after trephination and five times EBP treatment. It shows that targeted EBP was useful in refractory SIH, and also can be performed safely prior to drainage of the hematoma.
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Affiliation(s)
- Nan Liu
- Department of Anesthesiology, Hangzhou Xiasha Hospital, Zhejiang, People's Republic of China
| | - Yue Fei
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, People's Republic of China
| | - Fei-Fang He
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, People's Republic of China
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Incidence of Spinal CSF Leakage on CT Myelography in Patients with Nontraumatic Intracranial Subdural Hematoma. Diagnostics (Basel) 2021; 11:diagnostics11122278. [PMID: 34943515 PMCID: PMC8699929 DOI: 10.3390/diagnostics11122278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 01/24/2023] Open
Abstract
The aim of the present study was to demonstrate the incidence of spinal cerebrospinal fluid (CSF) leaks in patients with nontraumatic intracranial subdural hematoma (SDH) and determine clinical parameters favoring such leaks. This retrospective study was approved by the institutional review board. Patients diagnosed with nontraumatic intracranial SDH who underwent computed tomography (CT) myelography between January 2012 and March 2018 were selected. 60 patients (male: female, 39:21; age range, 20–82 years) were enrolled and divided into CSF leak-positive and CSF leak-negative groups according to CT myelography data. Clinical findings were statistically compared between the two groups. Spinal CSF leak was observed in 80% (48/60) of patients, and it was significantly associated with an age of <69 years (p = 0.006). However, patients aged ≥69 years also had a tendency to exhibit spontaneous intracranial hypotension (SIH)-induced nontraumatic intracranial SDH (60.87%; 14/23). Therefore, CT myelography is recommended to be performed for the evaluation of possible SIH in patients with nontraumatic intracranial SDH, particularly those aged <69 years. Patients aged ≥69 years are also good candidates for CT myelography because SIH tends to occur even in this age group.
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Yokoya S, Oka H, Hino A. Cerebral venous thrombosis following spontaneous intracranial hypotension diagnosed by craniotomy: A case report and diagnostic pitfalls. Surg Neurol Int 2021; 12:367. [PMID: 34513134 PMCID: PMC8422431 DOI: 10.25259/sni_546_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Cerebral vein and dural sinus thrombosis (CVT) is a rare but important complication of spontaneous intracranial hypotension (SIH). The diagnosis is difficult in cases lacking typical symptoms and typical imaging findings. Case Description: A 29-year-old male patient with a seizure attack was admitted to our hospital. Based on the head imaging findings, we misdiagnosed the patient with primary cerebral parenchymal lesion and performed an open biopsy. However, during the procedure, the patient was diagnosed with low cerebrospinal fluid pressure and cerebral cortical vein thrombosis. Conclusion: Thus, CVT due to SIH should be considered as a probable cause of secondary parenchymal lesions.
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Affiliation(s)
- Shigeomi Yokoya
- Department of Neurosurgery, Saiseikai Shiga Hospital, Ritto, Shiga, Japan
| | - Hideki Oka
- Department of Neurosurgery, Saiseikai Shiga Hospital, Ritto, Shiga, Japan
| | - Akihiko Hino
- Department of Neurosurgery, Saiseikai Shiga Hospital, Ritto, Shiga, Japan
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Abstract
This article introduces the basic concepts of intracranial physiology and pressure dynamics. It also includes discussion of signs and symptoms and examination and radiographic findings of patients with acute cerebral herniation as a result of increased as well as decreased intracranial pressure. Current best practices regarding medical and surgical treatments and approaches to management of intracranial hypertension as well as future directions are reviewed. Lastly, there is discussion of some of the implications of critical medical illness (sepsis, liver failure, and renal failure) and treatments thereof on causation or worsening of cerebral edema, intracranial hypertension, and cerebral herniation.
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Affiliation(s)
- Aleksey Tadevosyan
- Department of Neurology, Tufts University School of Medicine, Beth Israel Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Joshua Kornbluth
- Department of Neurology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Box#314, Boston, MA 02111, USA
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Okuma Y, Hirotsune N, Sotome Y, Kegoya Y, Matsuda Y, Sato Y, Tomita Y, Tanabe T, Muraoka K, Nishino S, Daido S. Middle meningeal artery embolization for chronic subdural hematoma with cerebrospinal fluid hypovolemia: A report of 2 cases. Neurochirurgie 2021; 68:123-128. [PMID: 33667531 DOI: 10.1016/j.neuchi.2021.02.008] [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: 08/04/2020] [Revised: 02/06/2021] [Accepted: 02/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) with cerebrospinal fluid hypovolemia syndrome (CHS) remains refractory to standard treatment with hematoma drainage by burr hole and irrigation and/or epidural blood patch. Previously, we reported the utility of middle meningeal artery (MMA) embolization for intractable CSDH. In this study, we present the usefulness of MMA embolization as a treatment for CSDHs with CHSs. CASES We present two cases of CSDHs with CHSs occurring in patients, 1 treated with burr hole craniotomy and irrigation, and the other treated with the epidural blood patch. Both patients exhibited similar-appearing bilateral relatively-thin hematomas, hyperplasia, and enhanced contrast effects in the dura mater, and extradural hygroma in the cervical portion on enhanced magnetic resonance imaging scans. Also, to reviewing prior literature and imaging findings, they had already undergone conventional treatment. We added MMA embolization treatment and they followed a good course. RESULTS Despite the known intractable outcomes of patients with CSDHs with CHSs, MMA embolization worked well in the current case series. CONCLUSION MMA embolization might be considered as a preferred therapeutic option for CSDHs with CHSs in order to buy time before the epidural blood patch starts working.
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Affiliation(s)
- Y Okuma
- Department of Neurological Surgery, Fukuyama City Hospital, Fukuyama, Japan; Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan.
| | - N Hirotsune
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Y Sotome
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Y Kegoya
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Y Matsuda
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Y Sato
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Y Tomita
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - T Tanabe
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - K Muraoka
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - S Nishino
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - S Daido
- Department of Neurological Surgery, Fukuyama City Hospital, Fukuyama, Japan
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Zou L, Li G, Zhao J, Zhang Y, Hou K. Management of spontaneous cerebrospinal fluid hypovolemia-associated massive chronic subdural hematoma with reinforced restriction of physical activity: report of three cases. J Int Med Res 2020; 48:300060520969321. [PMID: 33213246 PMCID: PMC7683931 DOI: 10.1177/0300060520969321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Spontaneous cerebrospinal fluid hypovolemia (SCFH) is an uncommon entity in neurosurgical practice. Without early recognition and management, some patients with SCFH can develop chronic subdural hematoma (CSDH). Generally, management of patients with SCFH without CSDH is relatively straightforward. However, this circumstance becomes more complicated in patients with concurrent CSDH. Treatment measures simply based on the respective management principles of SCFH and CSDH are insufficient or even disastrous. Our previous study showed that reinforced restriction of physical activity was a promising strategy in managing CSDH in the general population. We applied this strategy in three consecutive patients with SCFH and massive CSDH. All of the patients experienced complete resolution of CSDH. This study not only enriches the basic theory of formation and progression of CSDH, but also demonstrates that reinforced restriction of physical activity could be treated as an alternative or adjuvant management of CSDH secondary to SCFH.
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Affiliation(s)
- Lanhua Zou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jinchuan Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Zhang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
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15
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Shim HK, Park YK. Misdiagnosis of Spontaneous Intracranial Hypotension Presenting as Acute Mental Deterioration Caused by Unilateral Acute Subdural Hematoma: Case Report. Korean J Neurotrauma 2020; 16:254-261. [PMID: 33163434 PMCID: PMC7607012 DOI: 10.13004/kjnt.2020.16.e32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 01/23/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) is usually a benign disease which mostly present as orthostatic headache and resolves by conservative treatment or epidural blood patch. However, in severe cases large subdural hematoma or brain caudal herniation can progress to brain herniation and neurologic complications. We introduce a rare case of SIH which presented as acute mental deterioration with unilateral acute subdural hematoma. A 60 years old female visited to emergency room for stuporous mental change and unilateral acute subdural hematoma. Decompressive craniectomy and hematoma removal was performed to release brain herniation and increased intracranial pressure. There was temporary improvement of consciousness, but sustained leakage of cerebrospinal fluid (CSF) and caudal brain herniation worsened patient's condition. After recognizing that CSF leakage and hypovolemia was the underlying disease, emergent epidural blood patch and early cranioplasty was performed. After treatment CSF volume was normalized and patient recovered completely without neurologic deficits. Acute mental deterioration with unilateral subdural hematoma is a rare presentation for SIH. Treatment strategy for subdural hematoma with concomitant SIH patients, should be planned carefully with concerns to CSF hypovolemia and intracranial pressure.
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Affiliation(s)
- Hyeong Kyun Shim
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yung Ki Park
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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16
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Perez-Vega C, Robles-Lomelin P, Robles-Lomelin I, Diaz-Alba A, Navarro VG. Acute subdural hematoma recurrence during drain removal associated with spontaneous intracranial hypotension - A non-reported complication. Surg Neurol Int 2020; 11:316. [PMID: 33093993 PMCID: PMC7568103 DOI: 10.25259/sni_385_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/02/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is an uncommon, benign, and generally self-limiting condition caused by low cerebrospinal fluid (CSF) volume and pressure usually caused by a CSF leak. Patients with SIH have an increased incidence of subdural hematomas (SDH), which may be bilateral and recurrent. CASE DESCRIPTION We report a unique case of a man presenting with SIH and bilateral SDH that were drained with bilateral craniotomies. During drain removal, the patient had an acute neurological deterioration and a CT scan showed SDH recurrence. The patient had two new recurrent SDH afterwards. After the third surgical intervention, the drain was removed in the OR with concomitant subdural saline infusion, there was no recurrence of SDH after that and the patient has had no further complications after a 2-year follow-up. CONCLUSION Patients with intracranial hypotension are predisposed to form SDH. In this case, drain removal caused further decrease in intracranial pressure and triggered a new SDH formation, subdural saline irrigation masked atmospheric pressure and prevented this complication from happening again.
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Affiliation(s)
- Carlos Perez-Vega
- School of Medicine and Health Sciences, Tecnologico de Monterrey, Zapopan, Jalisco, Mexico
| | - Pilar Robles-Lomelin
- School of Medicine and Health Sciences, Tecnologico de Monterrey, Zapopan, Jalisco, Mexico
| | - Isabel Robles-Lomelin
- School of Medicine and Health Sciences, Tecnologico de Monterrey, Zapopan, Jalisco, Mexico
| | - Alexandra Diaz-Alba
- School of Medicine and Health Sciences, Tecnologico de Monterrey, Zapopan, Jalisco, Mexico
- Department of Neurology, Instituto Neurologico de Guadalajara S.C., Guadalajara, Jalisco, Mexico
| | - Victor Garcia Navarro
- School of Medicine and Health Sciences, Tecnologico de Monterrey, Zapopan, Jalisco, Mexico
- Department of Neurology, Instituto Neurologico de Guadalajara S.C., Guadalajara, Jalisco, Mexico
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17
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Ferrante E, Trimboli M, Petrecca G, Allegrini F, Ferrante MM, Rubino F. Management of Spontaneous Intracranial Hypotension During Pregnancy: A Case Series. Headache 2020; 60:1777-1787. [DOI: 10.1111/head.13942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Enrico Ferrante
- Neurology Department AOR San Carlo Potenza Italy
- Neurology Department Alto Vicentino Hospital – AULSS 7 Pedemontana Santorso Italy
| | - Michele Trimboli
- Neurology Department AOR San Carlo Potenza Italy
- Department of Medical and Surgical Sciences Institute of Neurology AOU Mater Domini – Magna Græcia University Catanzaro Italy
| | - Giuseppe Petrecca
- Anesthesiology and Intensive Care Department AOR San Carlo Potenza Italy
| | | | | | - Fabio Rubino
- Palliative Care and Pain Management Department ASST Valtellina Sondrio Italy
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18
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Podkovik S, Kashyap S, Bonda S, Bowen I, Calayag M. Spontaneous Intracranial Hypotension: Case Study and Review of the Literature. Cureus 2020; 12:e7018. [PMID: 32211254 PMCID: PMC7081740 DOI: 10.7759/cureus.7018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a pathology characterized by orthostatic headaches, diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI), and low to normal cerebrospinal fluid (CSF) pressures. We present the case of a 46-year-old male with refractory postural headaches, found to have a diffuse CSF leak throughout the cervicothoracic (C1-T12) spine. His neurological status declined rapidly to a Glasgow Coma Scale (GCS) of eight, necessitating bilateral subdural drain placement. Despite an overall brisk neurologic recovery, the patient remained unable to speak for nearly a week after the return of the remainder of his function. This raised the concern for possible cerebellar mutism. We review the multiple modalities used in this patient's treatment and explore possible explanations for the failure of initial therapy. The placement of bilateral subdural drains was a temporizing measure to treat the patient's neurologic decline, but it was likely the epidural blood patch with prolonged bedrest that hastened the patient's recovery. His speech function also returned with time and repeated therapy.
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Affiliation(s)
- Stacey Podkovik
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Samir Kashyap
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Sruthi Bonda
- Neurosurgery, Touro University College of Osteopathic Medicine California, Vallejo, USA
| | - Ira Bowen
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Mark Calayag
- Neurosurgery, Kaiser Permanente Fontana Medical Center, Fontana, USA
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19
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Spontaneous intracranial hypotension: review and expert opinion. Acta Neurol Belg 2020; 120:9-18. [PMID: 31215003 DOI: 10.1007/s13760-019-01166-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/06/2019] [Indexed: 12/20/2022]
Abstract
Spontaneous intracranial hypotension (SIH) results from spinal cerebrospinal fluid (CSF) leaking. An underlying connective tissue disorder that predisposes to weakness of the dura is implicated in spontaneous spinal CSF leaks. During the last decades, a much larger number of spontaneous cases are identified and a far broader clinical SIH spectrum is recognized. Orthostatic headache is the main presentation symptom of SIH; some patients also have other manifestations, mainly cochlear-vestibular signs and symptoms. Differential diagnosis with other syndromes presenting with orthostatic headache is crucial. Brain CT, brain MR, spine MRI, and MRI myelography are the imaging modalities of first choice for SIH diagnosis. Invasive imaging techniques, such as myelography, CT myelography, and radioisotopic cisternography, are progressively being abandoned. No randomized clinical trials have assessed the treatment of SIH. In a minority of cases, SIH resolved spontaneously or with only conservative treatment. If orthostatic headache persists after conservative treatment, a lumbar epidural blood patch (EBP) without previous leak identification (so-called "blind" EBP) is a widely used initial intervention and may be repeated several times. If EBPs fail, after the CSF leak sites identification using invasive imaging techniques, other therapeutic approaches include: a targeted epidural patch, surgical reduction of dural sac volume, or direct surgical closure. The prognosis is generally good after intervention, but serious complications may occur. More research is needed to better understand SIH pathophysiology to refine imaging modalities and treatment approaches and to evaluate clinical outcomes.
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20
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Ferrante E, Trimboli M, Pontrelli G, Rubino F. Early coma awakening after epidural blood patch. J Clin Neurosci 2020; 71:295-296. [DOI: 10.1016/j.jocn.2019.08.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/11/2019] [Accepted: 08/16/2019] [Indexed: 12/29/2022]
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21
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Chan SM, Chodakiewitz YG, Maya MM, Schievink WI, Moser FG. Intracranial Hypotension and Cerebrospinal Fluid Leak. Neuroimaging Clin N Am 2019; 29:213-226. [DOI: 10.1016/j.nic.2019.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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22
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Kim JH, Roh H, Yoon W, Kwon T, Chong K, Hwang S, Kim JH. Clinical Features of Patients With Spontaneous Intracranial Hypotension Complicated With Bilateral Subdural Fluid Collections. Headache 2019; 59:775-786. [DOI: 10.1111/head.13525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Jang Hun Kim
- Department of Neurosurgery Korean Armed Forces Capital Hospital Gyeonggi‐do Republic of Korea
- Department of Neurosurgery Guro Hospital, Korea University College of Medicine Seoul Republic of Korea
| | - Haewon Roh
- Department of Neurosurgery Guro Hospital, Korea University College of Medicine Seoul Republic of Korea
| | - Won‐Ki Yoon
- Department of Neurosurgery Guro Hospital, Korea University College of Medicine Seoul Republic of Korea
| | - Taek‐Hyun Kwon
- Department of Neurosurgery Guro Hospital, Korea University College of Medicine Seoul Republic of Korea
| | - Kyuha Chong
- Department of Neurosurgery Guro Hospital, Korea University College of Medicine Seoul Republic of Korea
| | - Soon‐Young Hwang
- Biostatistical Consulting Laboratory, Medical Science Research Center Korea University College of Medicine Seoul Republic of Korea
| | - Jong Hyun Kim
- Department of Neurosurgery Guro Hospital, Korea University College of Medicine Seoul Republic of Korea
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23
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Zhang H, Zhang X, Zheng D. Superior sagittal sinus thrombosis as a rare complication of spontaneous intracranial hypotension syndrome: a case report and review of the literature. Int J Neurosci 2018; 129:401-405. [PMID: 30345841 DOI: 10.1080/00207454.2018.1538144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In addition to an orthostatic headache, spontaneous intracranial hypotension syndrome can lead to subdural hematoma and diffusion, subarachnoid hemorrhage, and brain sag. However, cerebral venous sinus thrombosis is rarely reported in patients with spontaneous intracranial hypotension. We present the case of a 35-year-old male who developed an orthostatic headache, nausea, vomiting, and photophobia for 5 days. An enhanced brain magnetic resonance image showed extensive linear pachymeningeal enhancement in the bilateral cerebral hemispheres. Lumbar puncture showed that cerebrospinal fluid pressure was 80 mmH2O. Subsequent magnetic resonance scans demonstrated subdural effusion of the bilateral frontoparietal lobes, hyperintense T1-weighted images, and T2WI lesions within the superior sagittal sinus in 17 days. The patient was given low molecular weight heparin and adverse events occurred. Head computed tomography showed cerebral external fluid accumulation in the bilateral frontoparietal lobes. Then, digital subtraction angiography was performed at 22 days, which confirmed superior sagittal sinus thrombosis, and the patient recovered fully after therapy. The evolution of the disease and radiological findings support the diagnosis of spontaneous intracranial hypotension with superior sagittal sinus thrombosis. To the best of our knowledge, there are very few case reports describing superior sagittal sinus thrombosis as a complication of spontaneous intracranial hypotension. When spontaneous intracranial hypotension and cerebral venous thrombosis occur together, difficult practical questions arise regarding the treatment of these two conditions.
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Affiliation(s)
- Han Zhang
- a Department of Neurology , Shengjing Hospital of China Medical University , Tiexi District , Shenyang , China
| | - Xiaotian Zhang
- a Department of Neurology , Shengjing Hospital of China Medical University , Tiexi District , Shenyang , China
| | - Dongming Zheng
- a Department of Neurology , Shengjing Hospital of China Medical University , Tiexi District , Shenyang , China
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24
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De Lipsis L, Belmonte R, Cusano M, Giannetti MA, Muccio CF, Mancinelli M. Subdural Hematoma as a Consequence of Labor Epidural Analgesia. Asian J Neurosurg 2018; 13:931-934. [PMID: 30283586 PMCID: PMC6159069 DOI: 10.4103/ajns.ajns_115_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Subdural hematoma (SDH) following labor epidural analgesia is a rare neurological complication. SDH is a late complication of this procedure; it is caused by a leak of cerebrospinal fluid that may damage the vascular structures of the brain. Persistent headache in the days after labor epidural analgesia is a nonspecific clinical symptom caused by hematoma. Preexisting vascular malformations can be a concomitant cause of headache. Clinical cases have been reported even after epidural anesthesia. The differential diagnosis includes unspecified headache, sinusitis headache, drug-induced headache, cortical vein thrombosis, fistula of the dura mater, and bacterial, viral, and aseptic meningitis.
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Affiliation(s)
- Luca De Lipsis
- Department of Anesthesia, Sacred Heart of Jesus Hospital, Benevento, Italy
| | - Rossella Belmonte
- Department of Anesthesia, Sacred Heart of Jesus Hospital, Benevento, Italy
| | - Maria Cusano
- Department of Anesthesia, Sacred Heart of Jesus Hospital, Benevento, Italy
| | | | | | - Mauro Mancinelli
- Department of Radiology, Sacred Heart of Jesus Hospital, Benevento, Italy
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25
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Rath S, Shaikh A, Narwal P, Gupta A. New-onset headaches secondary to spontaneous intracranial hypotension. BMJ Case Rep 2018; 2018:bcr-2018-224240. [DOI: 10.1136/bcr-2018-224240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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