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Zetlaoui PJ, Buchheit T, Benhamou D. Epidural blood patch: A narrative review. Anaesth Crit Care Pain Med 2022; 41:101138. [DOI: 10.1016/j.accpm.2022.101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
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An S, Jeong HG, Seo D, Jo H, Lee SU, Bang JS, Oh CW, Kim T. Heavily T2-Weighted Magnetic Resonance Myelography as a Safe Cerebrospinal Fluid Leakage Detection Modality for Nontraumatic Subdural Hematoma. J Korean Neurosurg Soc 2022; 65:13-21. [PMID: 34763379 PMCID: PMC8752889 DOI: 10.3340/jkns.2020.0326] [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: 11/23/2020] [Revised: 01/18/2021] [Accepted: 03/26/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Nontraumatic subdural hematoma (SDH) is a common disease, and spinal cerebrospinal fluid (CSF) leakage is a possible etiology of unknown significance, which is commonly investigated by several invasive studies. This study demonstrates that heavily T2-weighted magnetic resonance myelography (HT2W-MRM) is a safe and clinically effective imaging modality for detecting CSF leakage in patients with nontraumatic SDH. METHODS All patients who underwent HT2W-MRM for nontraumatic SDH workup at our institution were searched and enrolled in this study. Several parameters were measured and analyzed, including patient demographic data, initial modified Rankin Scale (mRS) score upon presentation, SDH bilaterality, hematoma thickness upon presentation, CSF leakage sites, treatment modalities, follow-up hematoma thickness, and follow-up mRS score. RESULTS Forty patients were identified, of which 22 (55.0%) had CSF leakage at various spinal locations. Five patients (12.5%) showed no change in mRS score, whereas the remaining (87.5%) showed decreases in follow-up mRS scores. In terms of the overall hematoma thickness, four patients (10.0%) showed increased thickness, two (5.0%) showed no change, 32 (80.0%) showed decreased thickness, and two (5.0%) did not undergo follow-up imaging for hematoma thickness measurement. CONCLUSION HT2W-MRM is not only safe but also clinically effective as a primary diagnostic imaging modality to investigate CSF leakage in patients with nontraumatic SDH. Moreover, this study suggests that CSF leakage is a common etiology for nontraumatic SDH, which warrants changes in the diagnosis and treatment strategies.
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Affiliation(s)
- Sungjae An
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Han-Gil Jeong
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dongwook Seo
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyunjun Jo
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Risk factors for nonresponsive hydration in patients with spinal cerebrospinal fluid leakage. BMC Neurol 2021; 21:427. [PMID: 34732159 PMCID: PMC8564966 DOI: 10.1186/s12883-021-02464-6] [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: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spinal cerebrospinal fluid (CSF) leakage is frequently encountered clinically after lumbar puncture or spontaneous events. Although some patients recover without treatment or after intensive hydration, some require an epidural blood patch (EBP). The risks of nonresponsive hydration remain unknown. Therefore, we identified the risk factors for patients with spinal CSF leakage nonresponsive to hydration. METHODS We retrospectively reviewed patients diagnosed with spinal CSF leakage between January 2010 and March 2021. Clinical data, including patient age, sex, etiology, and radiological indications in magnetic resonance imaging, were compared between patients who were responsive and non-responsive to hydration. RESULTS Of the 74 patients with spinal CSF leakage, 25 were responsive to hydration and 49 required EBP. Patients who were nonresponsive to hydration were older (39.27 vs. 34.32 years, P = 0.01), had a higher percentage of spontaneous intracranial hypotension (93.88% vs. 68.00%, P = 0.005), had more spinal CSF leakage (12.04 vs. 8.04, P = 0.01), and had a higher percentage of dural sinus engorgement (81.63% vs. 60.00%, P = 0.044). Spontaneous intracranial hypotension (odds ratio [OR]: 4.63; 95% confidence interval [CI]: 1.00-21.38) and having ≥9 spinal CSF leakages (OR: 3.29; 95% CI: 1.08-10.01), as indicated by magnetic resonance myelography, are considered risk factors for noneffective hydration. CONCLUSIONS Patients with spinal CSF leakage who have spontaneous intracranial hypotension and those with ≥9 spinal CSF leakages are considered at risk for noneffective hydration. EBP should be considered early in these patients.
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Wei TT, Huang H, Chen G, He FF. Management of an intracranial hypotension patient with diplopia as the primary symptom: A case report. World J Clin Cases 2021; 9:6544-6551. [PMID: 34435024 PMCID: PMC8362549 DOI: 10.12998/wjcc.v9.i22.6544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/18/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intracranial hypotension (IH) is a disorder involving cerebrospinal fluid (CSF) hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed, especially in these patients without the prototypical manifestation of an orthostatic headache. At present, the management of IH with both cranial nerve VI palsy and bilateral subdural hematomas (SDHs) is still unclear.
CASE SUMMARY A 67-year-old male Chinese patient complained of diplopia on the left side for one and a half mo. Computed tomography revealed bilateral SDHs and a midline shift. However, neurotrophic drugs were not effective, and 3 d after admission, he developed a non-orthostatic headache and neck stiffness. Enhanced magnetic resonance imaging revealed dural enhancement as an additional feature, and IH was suspected. Magnetic resonance myelography was then adopted and showed CSF leakage at multiple sites in the spine, confirming the diagnosis of having IH. The patient fully recovered following multiple targeted epidural blood patch (EBP) procedures.
CONCLUSION IH is a rare disease, and to the best of our knowledge, IH with diplopia as its initial and primary symptom has never been reported. In this study, we also elucidated that it could be safe and effective to treat IH patients with associated cranial nerve VI palsy and bilateral SDHs using repeated EBP therapy.
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Affiliation(s)
- Ting-Ting Wei
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Hua Huang
- Department of Pain Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Gang Chen
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Fei-Fang He
- Department of Pain Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Bridwell RE, Larson NP, Baker M, Cibrario A, Oliver J. Postpartum Bilateral Subdural Hematomas: A Case Report. Cureus 2020; 12:e11191. [PMID: 33269122 PMCID: PMC7703702 DOI: 10.7759/cureus.11191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Postpartum headache is a common emergency department (ED) complaint in women following delivery. Though the majority of these headaches are due to primary headache disorders or postdural puncture headaches, life-threatening complications can occur. Both postpartum pre-eclampsia can occur as well as hypercoagulable and vascular disorders including stroke, venous sinus thrombosis (VST), and reversible cerebral vasoconstrictive syndrome. With the increasing use of epidurals for intrapartum analgesia, rare, dangerous complications can present in a similar fashion. The authors present a persistent postpartum headache secondary to bilateral subdural hematomas (SDH) from epidural induced intracranial hypotension.
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Treatment and outcome of subdural hematoma in patients with spontaneous intracranial hypotension: a report of 35 cases. Acta Neurol Belg 2018; 118:61-70. [PMID: 29052799 DOI: 10.1007/s13760-017-0845-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 10/01/2017] [Indexed: 01/13/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, low CSF pressure and diffuse pachymeningeal enhancement on brain MRI. SIH results from spontaneous CSF leakage leading to brain sag. Sometimes, tearing of bridging veins may produce subdural hematomas (SDHs). Patients with SDH were identified retrospectively from 212 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, treatment and outcome of SDH. Thirty-five patients (16%), (6 women, 29 men; aged 33-68; mean, 50 years) with SDH were recruited. They were divided into two groups: initially withSIH diagnosed (n = 29) and undiagnosed (n = 6). After conservative treatment, the first group underwent a lumbar epidural blood patch (EBP) (n = 27) and emergent evacuation of symptomatic SDH (n = 2). After EBP, ten patients had enlarged SDH. Nine of them underwent evacuation of symptomatic SDH with mass effect (ME). In the second group, three patients with clinical worsening from SIH underwent, erroneously, evacuation of mild SDH. They worsened after the evacuation; after SIH diagnosis was made, they underwent one EBP (n = 2) and three EBPs (the patient with coma). The other three cases with symptomatic SDH with ME underwent evacuation with recurrence of SDH (n = 2). All 35 patients enjoyed a good outcome. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation. When an emergent evacuation is necessary before EBP, it is preferable to perform, after surgery, one early EBP before the patient gets up to prevent frequent recurrences of SDH by underlying CSF leakage.
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Subdural hematoma after cesarean delivery without symptoms: a case report. JA Clin Rep 2018; 4:18. [PMID: 29497683 PMCID: PMC5820382 DOI: 10.1186/s40981-018-0151-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/22/2018] [Indexed: 11/30/2022] Open
Abstract
Background Subdural hematoma (SDH) after accidental dural puncture (ADP) is rare but may be lethal. We experienced a patient who developed SDH after combined spinal and epidural anesthesia without a headache. Case presentation A 41-year-old parturient female with an unruptured cerebral aneurysm, was scheduled to undergo elective cesarean delivery. Cerebrospinal fluid leakage was identified during puncture of the epidural space, and a catheter was placed after re-puncture. The postoperative course was normal except for incisional pain. The patient complained of slight neck stiffness on the second postoperative day. Magnetic resonance imaging (MRI) was performed to ensure that there was no intracranial problem on the fourth postoperative day and showed a bilateral subdural hematoma. Increase in size of hematoma was shown on computed tomography (CT) on the ninth postoperative day. Epidural blood patch was performed. A decrease in the size of the hematoma was confirmed on the CT images on the 11th postoperative day, and the patient was discharged. The patient has not developed any additional symptoms. Conclusions We experienced a patient who developed a SDH without a remarkable headache. It may be better to perform brain imaging studies, even if the patient does not complain of headache.
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Siedler DG, Ibbett IM, Thani NB. Surgical Management of Spontaneous Spinal Cerebrospinal Fluid Epidural Fistula. World Neurosurg 2017; 99:810.e5-810.e10. [DOI: 10.1016/j.wneu.2016.12.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 12/21/2022]
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Value of Targeted Epidural Blood Patch and Management of Subdural Hematoma in Spontaneous Intracranial Hypotension: Case Report and Review of the Literature. World Neurosurg 2017; 97:27-38. [DOI: 10.1016/j.wneu.2016.09.076] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/14/2016] [Accepted: 09/16/2016] [Indexed: 12/28/2022]
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Spontaneous Intracranial Hypotension: Characteristics of the Serious Form in a Series of 24 Patients. World Neurosurg 2015; 84:1613-20. [DOI: 10.1016/j.wneu.2015.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/03/2015] [Accepted: 07/04/2015] [Indexed: 12/26/2022]
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TAKAHASHI K, MIMA T, AKIBA Y. Chronic Subdural Hematoma Associated with Spontaneous Intracranial Hypotension: Therapeutic Strategies and Outcomes of 55 Cases. Neurol Med Chir (Tokyo) 2015; 56:69-76. [PMID: 26489406 PMCID: PMC4756246 DOI: 10.2176/nmc.oa.2015-0032] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 09/16/2015] [Indexed: 01/03/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) has increasingly been recognized, and it is well known that SIH is sometimes complicated by chronic subdural hematoma (SDH). In this study, 55 cases of SIH with SDH were retrospectively analyzed, focusing on therapeutic strategies and outcomes. Of 169 SIH cases (75 males, 84 females), 55 (36 males, 19 females) were complicated by SDH. SIH was diagnosed based on clinical symptoms, neuroimaging, and/or low cerebrospinal fluid pressure. Presence of orthostatic headache and diffuse meningeal enhancement on magnetic resonance imaging were regarded as the most important criteria. Among 55 SIH with SDH cases, 13 improved with conservative treatment, 25 initially received an epidural blood patch (EBP), and 17 initially underwent irrigation of the hematomas. Of the 25 initially treated with EBP, 7 (28.0%) needed SDH surgery and 18 (72.0%) recovered fully without surgery. Of 17 SDH cases initially treated with surgery, 6 (35.7%) required no EBP therapy and the other 11 (64.3%) needed EBP and/or additional SDH operations. In the latter group, 2 cases had transient severe complications during and after the procedures. One of these 2 cases developed a hoarse voice complication. Despite this single, non-severe complication, all enrolled in this study achieved good outcomes. The present study suggests that patients initially receiving SDH surgery may need additional treatments and may occasionally have complications. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation.
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Affiliation(s)
| | - Tatsuo MIMA
- Department of Neurosurgery, Sanno Hospital, Minato-ku, Tokyo
| | - Yoichi AKIBA
- Department of Neurosurgery, Akiba Hospital, Saitama, Saitama
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Ducros A, Biousse V. Headache arising from idiopathic changes in CSF pressure. Lancet Neurol 2015; 14:655-68. [DOI: 10.1016/s1474-4422(15)00015-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 12/24/2022]
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Xia P, Hu XY, Wang J, Hu BB, Xu QL, Zhou ZJ, Lou M. Risk factors for subdural haematoma in patients with spontaneous intracranial hypotension. PLoS One 2015; 10:e0123616. [PMID: 25853681 PMCID: PMC4390346 DOI: 10.1371/journal.pone.0123616] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 03/03/2015] [Indexed: 01/22/2023] Open
Abstract
Subdural haematoma (SDH) is a potentially life-threatening complication in patients with spontaneous intracranial hypotension (SIH). In serious cases, SIH patients who present with SDHs develop neurological deficits, a decreased level of consciousness, or cerebral herniation, and may even require an urgent neurosurgical drainage. Despite numerous publications on SDHs, few report its potential risk factors in patients with SIH. In this study, we retrospectively investigated 93 consecutive SIH patients and divided them into an SDH group (n = 25) and a non-SDH (NSDH) group (n = 68). The clinical and radiographic characteristics of these 93 patients were analyzed, and then univariate analysis and further multiple logistic regression analysis were performed to identify the potential risk factors for the development of SDHs. The univariate analysis showed that advanced age, male gender, longer clinical course, dural enhancement, and the venous distension sign were associated with the development of SDHs. However, multivariate analysis only included the latter three factors. Our study reveals important radiological manifestations for predicting the development of SDHs in patients with SIH.
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Affiliation(s)
- Ping Xia
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Xing-Yue Hu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Jin Wang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Bei-Bei Hu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Qing-Lin Xu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Zhi-Jie Zhou
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- * E-mail: (ML); (ZJZ)
| | - Min Lou
- Department of Neurology, 2nd Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
- * E-mail: (ML); (ZJZ)
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