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Choi SY, Seong M, Kim EY, Youn MS, Cho S, Jang H, Lee MJ. Outcome of epidural blood patch for imaging-negative spontaneous intracranial hypotension. Cephalalgia 2023; 43:3331024221140471. [PMID: 36739515 DOI: 10.1177/03331024221140471] [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: 02/06/2023]
Abstract
BACKGROUND Spontaneous intracranial hypotension is diagnosed by an abnormal finding in brain MRI, spinal imaging, or lumbar puncture. However, the sensitivity of each test is low. We investigated whether patients with suspected spontaneous intracranial hypotension and negative imaging findings would respond to epidural blood patch. METHODS We prospectively recruited patients with new-onset orthostatic headache admitted at the Samsung Medical Center from January 2017 to July 2021. In patients without abnormal imaging findings and no history of prior epidural blood patch, treatment outcome-defined as both 50% response in maximal headache intensity and improvement of orthostatic component-was collected at discharge and three months after epidural blood patch. RESULTS We included 21 treatment-naïve patients with orthostatic headache and negative brain and spinal imaging results who received epidural blood patch. After epidural blood patch (mean 1.3 times, range 1-3), 14 (66.7%) and 19 (90.5%) patients achieved both 50% response and improvement of orthostatic component at discharge and three months post-treatment, respectively. Additionally, complete remission was reported in 11 (52.4%) patients at three-month follow-up, while most of the remaining patients had only mild headaches. Among nine (42.9%) patients who underwent lumbar puncture, none had an abnormally low opening pressure (median 13.8 cm H2O, range 9.2-21.5). CONCLUSION Given the high responder rates of epidural blood patch in our study, empirical epidural blood patch should be considered to treat new-onset orthostatic headache, even when brain and spinal imaging are negative. The necessity of lumbar puncture is questionable considering the high response rate of epidural blood patch and low rate of "low pressure."
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Affiliation(s)
- So Youn Choi
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Minjung Seong
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eung Yeop Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Michelle Sojung Youn
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Hyemin Jang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Alzheimer's Disease Convergence Research Center, Samsung Medical Center, Seoul, South Korea
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Spontaneous intracranial hypotension: searching for the CSF leak. Lancet Neurol 2022; 21:369-380. [DOI: 10.1016/s1474-4422(21)00423-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
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Dobrocky T, Häni L, Rohner R, Branca M, Mordasini P, Pilgram-Pastor S, Kaesmacher J, Cianfoni A, Schär RT, Gralla J, Raabe A, Ulrich C, Beck J, Piechowiak EI. Brain Spontaneous Intracranial Hypotension Score for Treatment Monitoring After Surgical Closure of the Underlying Spinal Dural Leak. Clin Neuroradiol 2022; 32:231-238. [PMID: 35028683 DOI: 10.1007/s00062-021-01124-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is a debilitating condition requiring effective treatment; however, objective data on treatment response are scarce. PURPOSE To assess the suitability of the brain MRI-based SIH score (bSIH) for monitoring treatment success in SIH patients with a proven spinal cerebrospinal fluid (CSF) leak after microsurgical closure of the underlying dural breach. METHODS This retrospective cohort study included consecutive SIH patients with a proven spinal CSF leak, investigated at dedicated referral centre January 2012 to March 2020. The bSIH score integrates 6 imaging findings; 3 major (2 points) and 3 minor (1 point), and ranges from 0 to 9, with 0 indicating low and 9 high probability of spinal CSF loss. The score was calculated using brain magnetic resonance imaging (MRI) before and after surgical treatment of the underlying CSF leak. Headache intensity was registered on a numeric rating scale (NRS) (range 0-10). RESULTS In this study 52 SIH patients, 35 (67%) female, mean age 45.3 years, with a proven spinal CSF leak were included. The mean bSIH score decreased significantly from baseline to after surgical closure of the underlying dural breach (6.9 vs. 1.3, P < 0.001). A decrease in the NRS score was reported (8.6 vs. 1.2, P < 0.001). CONCLUSION The bSIH score is a simple tool which may serve to monitor treatment success in SIH patients after surgical closure of the underlying spinal dural leak. Its decrease after surgical closure of the underlying spinal dural breach indicates restoration of an equilibrium within the CSF compartment.
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Affiliation(s)
- Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland. .,Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany.
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Roman Rohner
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Mattia Branca
- Clinical Trial Unit, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Sara Pilgram-Pastor
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Alessandro Cianfoni
- Department of Neuroradiology, Neurocenter of Italian Switzerland, Lugano, 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, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christian Ulrich
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, 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
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
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Angelopoulou E, Pantou E, Zacharis G, Rentzos M, Stefanis L, Zouvelou V. Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00109-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Spontaneous intracranial hypotension (SIH) is characterized by positional headache caused by low CSF pressure, without any major traumatic event. Optimal treatment is still debated; epidural blood patch (EBP) is usually used after unsuccessful conservative treatment with variable efficacy and potentially severe complications. Although steroids have been reported to be beneficial, their effectiveness is still controversial, and more clinical evidence is needed.
Case presentation
A 37-year-old woman was admitted to the neurology department due to severe orthostatic headache with nausea over the last 5 days. No trauma history or spinal manipulation were mentioned. On arrival, neurological examination, brain CT, and laboratory investigation were normal. Intracranial hypotension was clinically suspected, and lumbar puncture revealed low opening pressure. Brain MRI demonstrated pachymeningeal gadolinium enhancement and distended and rounded dural venous sinuses, while cervicothoracic spine MRI revealed thoracic CSF leakage, leading to SIH diagnosis. The patient was treated with high-dose intravenous methylprednisolone, with complete clinical resolution within 24 h.
Conclusions
Our case, combined with literature evidence, supports the high-dose intravenous corticosteroids as a reasonable treatment option in selected cases, before trying EBP or surgical repair. Randomized clinical trials are needed, in order to optimize SIH patients’ outcomes.
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Patel D, Saindane A, Oyesiku N, Hu R. Variant sella morphology and pituitary gland height in adult patients with Chiari II malformation: potential pitfall in MRI evaluation. Clin Imaging 2020; 64:24-28. [PMID: 32217423 DOI: 10.1016/j.clinimag.2020.02.014] [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: 08/10/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To systematically evaluate the sella morphology and pituitary gland height on brain MRI of Chiari II malformation (C2M) patients to understand the observed high incidence of apparent enlargement of the pituitary gland. METHODS Brain MRIs of C2M patients at a single tertiary care adult institution were retrospectively reviewed. We also evaluated two age and gender-matched control groups-patients with normal brain MRI (C1 group) and chronic ventricular shunts (C2 group). The heights of tuberculum sella, dorsum sella, and pituitary gland were measured and compared. The presence or absence of dural thickening was noted. RESULTS 21 patients were included in each group. In C2M group, a pituitary adenoma was suggested on 24% of the MRIs. The dorsum sella was significantly smaller in the C2M group (4.8 mm) compared to both the C1 group (7.4 mm, p < 0.001) and the C2 group (7.1 mm, p < 0.001). The pituitary gland was also larger in the cranial-caudal dimension in C2M group (8.6 mm) as compared to both the C1 group (6.6 mm, p < 0.01) and the C2 group (6.0 mm, p < 0.001). One C2M patient with a pituitary gland<10 mm was suggested to have a pituitary adenoma on outside MRI, although a normal pituitary gland was seen on pathology. CONCLUSION C2M patients have shallow sella which can accentuate the pituitary gland height. The mean pituitary height was larger in C2M patients, but no functional pituitary pathology was present. It is important to consider sella morphology when evaluating the pituitary gland of C2M patients to avoid unnecessary medical and surgical interventions.
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Affiliation(s)
- Dhruv Patel
- Department of Radiology & Imaging Sciences, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA 30322, United States of America.
| | - Amit Saindane
- Department of Radiology & Imaging Sciences, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA 30322, United States of America.
| | - Nelson Oyesiku
- Department of Neurosurgery, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA 30322, United States of America.
| | - Ranliang Hu
- Department of Radiology & Imaging Sciences, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA 30322, United States of America.
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Ozyigit A, Michaelides C, Natsiopoulos K. Spontaneous Intracranial Hypotension Presenting With Frontotemporal Dementia: A Case Report. Front Neurol 2018; 9:673. [PMID: 30174645 PMCID: PMC6107704 DOI: 10.3389/fneur.2018.00673] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/26/2018] [Indexed: 11/25/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a rare and often underdiagnosed condition, which commonly results from a cerebrospinal fluid leak. The classic clinical presentation of SIH is a postural headache and dizziness. Less frequent complications include nausea, neck stiffness, and even coma. This case report describes a 70-year-old woman with an initial complaint of postural headaches and sleep attacks, who developed a 22-month progressive history of personality and behavioral changes, cognitive decline, urinary incontinence, chorea, and dysarthria. Although no specific cerebrospinal fluid leak was identified, the patient was suspected of having SIH and her symptoms completely reversed after a 2-month course of steroids. This case highlights that SIH represents a rare and reversible cause of a wide spectrum of neurological symptoms, including dementia. Neurologists should be aware of this diagnosis when evaluating patients with neurological signs and symptoms that cannot otherwise be explained.
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Affiliation(s)
- Ahmet Ozyigit
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Costas Michaelides
- Department of Neurology, American Medical Center, Nicosia, Cyprus.,Department of Neurology, University of Nicosia Medical School, Nicosia, Cyprus
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Lin JP, Zhang SD, He FF, Liu MJ, Ma XX. The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain 2017; 18:4. [PMID: 28091819 PMCID: PMC5236046 DOI: 10.1186/s10194-016-0708-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/07/2016] [Indexed: 01/03/2023] Open
Abstract
Intracranial hypotension, especially spontaneous intracranial hypotension (SIH), is a well-recognized entity associated with cerebrospinal fluid (CSF) leaks, and has being recognized better in resent years, while still woefully inadequate. An increasing number of factors including iatrogenic factors are realized to involve in development and progression of intracranial hypotension. The diagnosis remains difficult due to the various clinical manifestations, some of which are nonspecific and easily to be neglected. Multiple imaging tests are optional in CSF leakage identification while clinicians are still confronted with difficulties when making selection resulting from superiorities and disadvantages of different imaging tests. Treatments for intracranial hypotension are multifarious but evidence is anecdotal. Values of autologous epidural blood patching (EBP), the mainstay of first-line interventional treatment currently, is getting more and more regards while there are no systematic review of its efficacy and risks. Hereby, the purpose of this review was to reveal the present strategy of intracranial hypotension diagnosis and treatment by reviewing literatures, coupled with our experience in clinical work.
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Affiliation(s)
- Jin-Ping Lin
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Shu-Dong Zhang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Fei-Fang He
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China.
| | - Min-Jun Liu
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Xiao-Xu Ma
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
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