Intracranial hypotension with spinal pathology

Effect of blind versus fluoroscopic guidance epidural blood patch in patients with intracranial hypotension

Epidural blood patch (EBP)-the most effective treatment for intracranial hypotension (IH)-can be performed using the blind technique in the lateral position or under fluoroscopic guidance in the prone position. This study aimed to compare the effectiveness of EBP in patients with spontaneous intracranial hypotension (sIH) and iatrogenic intracranial hypotension (iIH) when performed with the blind technique in the lateral decubitus position or fluoroscopic guidance in the prone position. We reviewed IH patients who underwent EBP between January 2015 and September 2019 in a single hospital and divided them into two groups according to the type of IH. Of the 84 included patients, 36 had sIH and 48 had iIH. We compared the effectiveness of EBP using the two methods in each group. There was no significant difference in the effect of EBP between the patients with iIH (p > 0.05). For patients with sIH, fluoroscopic guidance in the prone position technique showed better improvement than the blind technique in the lateral decubitus position (p < 0.05). We observed similar outcomes after blind EBP versus fluoroscopic guidance EBP in patients with iIH. However, procedure-dependent differences were observed in patients with sIH. For patients with sIH, it would be effective to consider fluoroscopic EBP first. Further study is needed to investigate interactions between method of EBP and other factors that affect the effectiveness of EBP.

Fluctuating hearing loss secondary to spontaneous intracranial hypotension: A case report and review of the literature

OBJECTIVE

Fluctuating sensorineural hearing loss (SNHL) has multiple etiologies, most commonly Ménière's disease (MD), recurrent sudden SNHL, and autoimmune inner ear disorders. Fluctuating SNHL has rarely been described as a symptom of spontaneous intracranial hypotension (SIH).

PATIENT

A 39-year-old previously healthy female presented with "Ménière's like" symptoms responsive to steroid treatment, which worsened during the day and improved in the supine position. Conservative treatment for MD consisting of low salt and caffeine diet and betahistine medication yielded no improvement. Secondary revision of brain imaging scans showed signs indicative of SIH, and a spinal cerebrospinal fluid leak was ultimately found and treated by a novel technique of transvenous fistula embolization by means of Onyx® glue, leading to gradual clinical improvement and near-complete resolution of symptoms.

CONCLUSION

SIH should be considered as part of the differential diagnosis of fluctuating SNHL. Clinical and radiological features should be known and sought. We suspect that early diagnosis and treatment can lead to cure and prevent permanent auditory damage.

Spontaneous Intracranial Hypotension Occurring after Craniotomy for Brain Tumor Biopsy Mimicking Postoperative Bleeding

In this study, we report on a previously healthy 44-year-old man who underwent an open biopsy under general anesthesia for a tumorous lesion found in his left frontal lobe via a small supratentorial craniotomy. While both postoperative course and brain computed tomography (CT) scans had been considered unremarkable, the patient became stuporous on postoperative day (POD) 4. A brain CT obtained on that day showed a subdural hematoma with marked brain shift which we thought might have been due to postoperative bleeding; he was immediately brought to an operating theater for hematoma removal. However, no bleeding source was found, and the brain remained depressed after hematoma evacuation. Furthermore, the brain shift remained unchanged on postoperative CT. While spontaneous intracranial hypotension (SIH) was considered, imaging studies to search for possible cerebrospinal fluid (CSF) leakage in the spinal column were not performed as the patient's condition has improved. However, he became stuporous again on POD 8, which urged us to perform CT myelogram. The CT myelogram showed a massive CSF leakage at the L1-L2 level. Subsequent autologous blood patch has successfully terminated the CSF leakage, and he became fully oriented shortly after the blood patch therapy. Thus, it should be noted that SIH may occur during postoperative period of intracranial surgery, and it may manifest radiographically as a subdural hematoma indistinguishable from postoperative bleeding. SIH should also be included in a differential diagnosis of postoperative headache, regardless of its characteristics, because headache associated with SIH may not always be orthostatic.

Diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension: a systematic review and meta-analysis

OBJECTIVES

To investigate the pooled diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension (SIH).

METHODS

A literature search of the MEDLINE/PubMed and Embase databases was conducted until July 25, 2021, including studies with the following inclusion criteria: (a) population: patients with newly diagnosed SIH; (b) diagnostic modality: MR myelography or MR myelography with intrathecal gadolinium for evaluation of CSF leakage; (c) outcomes: diagnostic yield of MR myelography or MR myelography with intrathecal gadolinium. The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects modeling was used to calculate the pooled estimates. Subgroup analysis regarding epidural fluid collection and meta-regression were additionally performed.

RESULTS

Fifteen studies with 643 patients were included. Eight studies used MR myelography with intrathecal gadolinium, and 11 used MR myelography. The overall quality of the included studies was moderate. The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) and that of MR myelography with intrathecal gadolinium was 83% (95% CI, 51-96%). There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium (p = 0.512). In subgroup analysis, the pooled diagnostic yield of the epidural fluid collection was 91% (95% CI, 84-94%). In meta-regression, the diagnostic yield was unaffected regardless of consecutive enrollment, magnet strength, or 2D/3D.

CONCLUSIONS

MR myelography had a high diagnostic yield in patients with SIH. MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.

KEY POINTS

• The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) in patients with spontaneous intracranial hypotension. • There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium. • MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.

Targeted Anterior Cervical Epidural Blood Patch in a Patient with Spontaneous Intracranial Hypotension

A 45-year-old male was admitted with severe orthostatic headache secondary to spontaneous intracranial hypotension. He had the site of cerebrospinal fluid (CSF) leakage identified at the anterolateral aspect of the C7-T1 spinal level. He first underwent a conventional posterior-approach cervical epidural blood patch (EBP) which provided immediate relief to the patient’s symptoms; however, his symptoms recurred two days later. To better target the anterolateral leakage site, we employed an anterior-approach EBP under computed tomography (CT) guidance. After this attempt, the patient experienced complete relief of his symptoms, and the headache eventually resolved.

Epidural blood patch for spontaneous intracranial hypotension with subdural hematoma: A case report and review of literature

BACKGROUND

Cerebrospinal fluid (CSF) leakage at C1/2 in spontaneous intracranial hypotension (SIH) is rare. Subdural hematoma (SDH), a serious complication of SIH, may lead to neurological deficits. This report presents a case of SDH after spontaneous C1/2 CSF leakage, which was treated with a targeted epidural blood patch (EBP).

CASE SUMMARY

A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache, nausea, and vomiting. Brain computed tomography imaging revealed bilateral, subacute to chronic SDH. Brain magnetic resonance imaging (MRI) findings were SDH with dural enhancement in the bilateral cerebral convexity and posterior fossa and mild sagging, suggesting SIH. Although the patient underwent burr hole trephination, the patient’s orthostatic headache was aggravated. MR myelography led to a suspicion of CSF leakage at C1/2. Therefore, we performed a targeted cervical EBP using an epidural catheter under fluoroscopic guidance. At 5 d after EBP, a follow-up MR myelography revealed a decrease in the interval size of the CSF collected. Although his symptoms improved, the patient still complained of headaches; therefore, we repeated the targeted cervical EBP 6 d after the initial EBP. Subsequently, his headache had almost disappeared on the 8^th day after the repeated EBP.

CONCLUSION

Targeted EBP is an effective treatment for SDH in patients with SIH due to CSF leakage at C1/2.

Magnetic resonance imaging predicted the therapeutic response of patients with spinal cerebrospinal fluid leakage undergoing targeted epidural blood patch

OBJECTIVE

Most patients with spinal cerebrospinal fluid (CSF) leakage require an epidural blood patch (EBP); however, the response to treatment is varied. This study aimed to compare the MRI findings at follow-up between EBP effective and non-effective groups and to identify imaging findings that predict EBP treatment failure.

METHODS

We retrospectively reviewed 48 patients who received EBP treatment for spinal CSF leakage. These patients were stratified into two groups: EBP effective (n = 27) and EBP non-effective (n = 21) using the results of the 3 month MRI as the end point.

RESULTS

Compared to the EBP non-effective group, the patients in the EBP effective group had a lower spinal CSF leakage number (2.67 vs 12.48; p = 0.001), lower spinal epidural fluid accumulation levels (3.00 vs 7.48; p = 0.004), brain descend (11.11% vs 38.10%; p = 0.027), pituitary hyperemia (18.52% vs 57.14%; p = 0.007), and decreased likelihood of ≥three numbers of spinal CSF leakage (25.93% vs 90.48%; p = 0.001) in the post-EBP MRI. Clinical non-responsiveness (OR: 57.84; 95% CI: 3.47-972.54; p = 0.005) and ≥three numbers of spinal CSF leakage (OR: 15.13; 95% CI: 1.45-159.06; p = 0.023) were associated with EBP failure. Between these variables, ≥three numbers of spinal CSF leakage identified using the post-EBP MRI demonstrated greater sensitivity in predicting EBP failure compared to clinical non-responsiveness (90.48% vs 61.9%).

CONCLUSION

The number of spinal CSF leakage identified using the post-EBP MRI with a cut-off value of three is an effective predictor of EBP failure.

ADVANCES IN KNOWLEDGE

Compared to clinical responsiveness, the post-EBP MRI provided a more objective approach to predict the effectiveness of EBP treatment in patients with spinal CSF leakage.

Iatrogenic Intracranial Hypotension after Surgery of Adolescent Idiopathic Scoliosis due to a Misplaced Screw within the Thoracic Thecal Sac

We present the case of a postoperative intracranial hypotension due to a misplaced intrathecal screw. Although typical symptoms such as orthostatic headache were present immediately after surgery, diagnosis was hidden until 20 years later, resulting in a disastrous clinical course.

CT-Guided Autologous Blood Patch for High-Level Cervical Cerebrospinal Fluid Leakage: Imaging Characteristics and Treatment Safety and Efficiency

INTRODUCTION

Epidural blood patches (EBPs) are rarely performed at the high-level cervical levels. The aim of the study was to investigate the imaging features, safety, and effectiveness of CT-guided percutaneous EBPs for high-level cervical cerebrospinal fluid (CSF) leakage.

METHODS

Twenty-five patients with spontaneous high-level (C1-C3) CSF leakage on MRI and CT imaging, including 2 patients with intracranial epidural hematoma caused by CSF, were treated with EBP. Two needles were inserted into the C1-3 bilateral epidural space. The needle location was confirmed by injection of both 3-5mL sterile air and a diluted iodinated contrast agent to delineate its spatial diffusion. The patient's blood 11.1 ± 3.1 mL was slowly injected to make a patch; the distribution in epidural space was monitored with intermittent CT scanning.

RESULTS

The typical manifestation of CSF leakage was the high signal outside the C1-3 cervical dura on MR T2W fat inhibition images and low density in cervical muscle space on CT images. Twenty patients suffered from headaches and were able to sit and walk 24 h after the operation. Four patients, with partial relief of headache and a small but persistent CSF leakage, were re-treated with EBS. One patient underwent a third operation because of a persistent CSF leakage on MRI.

CONCLUSIONS

Imaging of water at the surrounding epidural space of high cervical level is a typical feature of dural rupture on both MRI and CT. CT-guided EBP is safe and efficient for the high-level cervical CSF leakage, especially for cases in which conservative treatments failed.

An unusual postural headache: a case report

BACKGROUND

This paper presents a case of an evolving unusual thunderclap headache that presented to a chiropractor.

CASE PRESENTATION

The intense "migraine-like" headache was aggravated by standing up and relieved substantially when lying down. This low pressure, orthostatic headache was diagnosed as a spontaneous intracranial hypotension (SIH) secondary to a spontaneous tear of the dura. It was referred to the local hospital for management with autogolous blood injection to form an epidural blood patch of the defect. It resolved substantially within 3 days.

CONCLUSIONS

The significance of key features in the history and examination and how if not recognised and subsequently treated with manual therapy, the dural tear could be attributed to the treatment of the chiropractor, a treatment that would typically involve cervical manipulation. Discussion is provided of the implications of a missed diagnosis and possible subsequent chiropractic management with the evolving SIH being attributed to the chiropractic intervention rather than its true "spontaneous" nature.

Persistence and regredience of intraspinal fluid collection determine symptom control in intracranial hypotension syndrome

Background and purpose

An intraspinal fluid collection (ISFC) can be observed on spinal MRI in cases of intracranial hypotension syndrome (IHS). The goal of this study was to analyze the possible persistence of ISFC after therapy and its correlation to clinical disease activity and secondary complications.

Materials and methods

Twenty patients in our database of 57 patients, who were treated for IHS between 2009 and 2015, fulfilled the inclusion criteria of (a) diagnosed and treated IHS as well as (b) an ISFC in MRI imaging. Ten of these participated in our study. We performed follow-up visits, which included a history, a clinical examination, and a spinal MRI.

Results

A MRI-confirmed ISFC was seen in six patients, five of which had symptoms attributable to chronic IHS. There were two cases of superficial siderosis. One patient had a persisting ISFC and was free of symptoms. Four patients did not have an ISFC and were free of symptoms (Fisher’s exact test; p < 0.048).

Conclusion

There is statistically significant correlation between the persistence of an ISFC after IHS treatment and ongoing clinical symptoms. Resolved symptoms seem to correlate with absorbed extradural ISFC and hypothetically closed leakage site. ISFC as confirmed by MRI proofs to be a reliable follow-up marker for disease activity in chronic IHS that is possibly even superior to clinical examination.

Subdural Hematoma Related to Dural Tear During Lumbar Spine Surgery: A Case Report and Review of the Literature

Subdural hematoma is a rare complication after lumbar spine surgeries. Most of the time, the reason for this complication is intracranial hypotension related to an unintended durotomy, and the main symptom is persistent orthostatic headache. The authors present the case of a-38-year-old woman who underwent lumbar discectomy. Three weeks after the surgery, she developed subdural hematoma related to dural tear during the procedure. Emergent hematoma evacuation with craniotomy and dural tear repair was performed simultaneously because of the herniation symptoms of the patient. Clinical findings, radiological assessments, and treatment modalities have been discussed in the presence of a literature review in this case report.

Transdural Thoracic Disk Herniation with Longitudinal Slitlike Dural Defect Causing Intracranial Hypotension: Report of 2 Cases

BACKGROUND

Intracranial hypotension (IH) has a widely variable clinical and radiologic presentation. Secondary IH may be caused by degenerative spine disorders and in particular by thoracic disk herniations (TDHs).

METHODS

We present 2 patients with a transdural TDH, a secondary IH, and superficial siderosis in 1.

RESULTS

Case 1 presented with headache, cognitive decline, staggering gait, bilateral subdural effusions, cerebral sagging, an extradural spinal cerebrospinal fluid (CSF) collection suggesting secondary IH, and a calcified TDH at T9-T10. Case 2 presented with intermittent pain at the craniocervical junction provoked exclusively by specific physical activities, superficial siderosis mainly in the posterior fossa, an extradural spinal CSF collection, and a calcified TDH at T7-T8 yet no intracranial signs of IH. In both cases, using strict thoracoscopic technique, we removed a transdural TDH and reconstructed an underlying longitudinal slitlike dural defect with smooth lining. Follow-up magnetic resonance imaging scans confirmed a dramatically improved situation without residual extradural intraspinal CSF collection or signs of IH.

CONCLUSIONS

This paper adds to the evidence that some cases of IH and even superficial siderosis are caused by transdural erosion of a TDH that may be otherwise asymptomatic. The dura may degenerate due to chronic compression, and a longitudinal slitlike dural defect with smooth lining may develop, causing continuous (Case 1) or intermittent (Case 2) intraspinal CSF leakage. To the best of our knowledge, such dural defects closely resembling the ones observed in idiopathic spinal cord herniation have never been demonstrated on intraoperative endoscopic video in IH patients.

Spontaneous intracranial hypotension in a patient with systemic lupus erythematosus

Spontaneous intracranial hypotension (SIH) associated with cerebrospinal fluid leak classically presents with postural headache. It is most commonly caused by the spontaneous dehiscence of a meningeal diverticulum or as a consequence of dural tears. The association between connective tissue disease and SIH is well known. However, the occurrence of SIH associated with systemic lupus erythematosus has rarely been reported. We present a 53 years old female with a history of systemic lupus erythematosus who was diagnosed with SIH. The patient was worked up with Magnetic resonance imaging and Computed tomographic myelography, and successfully treated with a nontargeted epidural blood patch. Furthermore, we review the current literature and focus on the various imaging techniques that can be used in the workup of a cerebrospinal fluid leak.

Pseudohypoxic Brain Swelling After Uncomplicated Lumbar Decompression and Fusion for Spondylolisthesis

BACKGROUND

Pseudohypoxic brain swelling (PHBS), also known as postoperative intracranial hypotension-associated venous congestion, is a rare complication after neurosurgery characterized by rapid and often severe postoperative deterioration in consciousness and distinct imaging findings on brain magnetic resonance imaging. Imaging findings associated with PHBS include computed tomography and magnetic resonance imaging findings that resemble hypoxic changes and intracranial hypotensive changes in basal ganglia and thalamus, telencephalic, and infratentorial regions without notable changes in intracranial vasculature.

CASE DESCRIPTION

This report describes the case of an L4-5 microdiskectomy with posterior decompression and fusion complicated by clinical and radiographic findings resembling PHBS without a known intraoperative durotomy.

CONCLUSIONS

Spine surgeons should be alerted to the possibility that PHBS may occur in patients even after an operation without known durotomy or cerebrospinal fluid leakage and with spontaneous clinical resolution unrelated to suction drainage changes or epidural blood patches.

Cerebrospinal Fluid Leakage at the Lumbar Spine: A Unique Cause of Delayed Neurologic Deterioration in a Traumatic Acute Subdural Hematoma Patient

We present a rare case of traumatic acute subdural hematoma (SDH) in which intracranial hypotension (IC) secondary to cerebrospinal fluid (CSF) leakage at the lumbar spine caused delayed neurological deterioration. A 70-year-old male sustained a head injury after ground-level fall and was brought to our institution. A brain computed tomography (CT) showed a thin acute SDH with mild brain shift, and conservative management was initiated. He exhibited neurological deterioration on the 9^th hospital day, however, and a brain CT showed a change in CT density and marked an increase in hematoma volume and brain shift. It was thought that conversion from acute to subacute SDH was associated with the deterioration, and emergency hematoma evacuation was performed. Despite the surgery, neither clinical nor radiographical improvement occurred. The lack of improvement pointed to the presence of underlying IC, and a CT myelography revealed the dural sleeve of the right L2 nerve root as the source of the CSF leakage. An epidural blood patch therapy was performed on the 12^th hospital day to seal the CSF leakage. The postprocedural course was uneventful, and the patient was discharged free of symptoms on the 20^th hospital day. Spinal CSF leakage should be considered as a cause of delayed neurological deterioration in patients with traumatic acute SDH which exhibits conversion to subacute SDH.

[Post-lumbar puncture syndrome]

This article presents a clinical case which describes some clinical aspects, risk factors, management and the prophylactic methods to prevent the post-lumbar puncture syndrome.

Surgical "Fat Patch" Improves Secondary Intracranial Hypotension Orthostatic Headache Associated with Lumbosacral Dural Ectasia

BACKGROUND

Secondary intracranial hypotension is a clinical syndrome associated with reduction of cerebrospinal fluid volume and dural continuity violation. The main symptoms are orthostatic headache associated with nausea, vomiting, diplopia, dizziness, and tinnitus. The treatment is usually nonspecific.

CASE DESCRIPTION

A 37-year-old woman developed secondary intracranial hypotension caused by lumbosacral iatrogenic dural ectasia following detethering surgery. An orthostatic headache was the mainstay of her clinical picture, and it was confirmed by intracranial pressure monitoring. Conservative treatment including spinal blood patch improved symptoms for a limited amount of time (<1 month). Altered compliance of the dural spinal sac was suspected. Therefore thecal sac remodeling by placing autologous fat at the level of the dural ectasia was performed, improving the symptoms for 2 years.

CONCLUSION

Volumetric reduction of the epidural space may be considered as a valuable therapeutic option in case of intracranial hypotension that is unresponsive to medical treatments and spinal blood patch, as well as when an altered compliance of the dural sac is hypothesized.

Application of time-spatial labeling inversion pulse magnetic resonance imaging in the diagnosis of spontaneous intracranial hypotension due to high-flow cerebrospinal fluid leakage at C1-2

BACKGROUND

Spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid (CSF) leakage at C1-2 poses diagnostic and therapeutic challenges to spine surgeons. Although computed tomography (CT) myelography has been the diagnostic imaging modality of choice for identifying the CSF leakage point, extradural CSF collection at C1-2 on conventional CT myelography or magnetic resonance imaging (MRI) may often be a false localizing sign.

CASE DESCRIPTION

The present study reports the successful application of time-spatial labeling inversion pulse (T-SLIP) MRI, which enabled the precise identification of the CSF leakage point at C1-2 in a 28-year-old woman with intractable SIH. After identifying the leakage point using both CT myelography and T-SLIP MRI, surgery was performed to seal the CSF leak. Intraoperatively, a pouch suggestive of an extradural arachnoid cyst around the left C2 nerve root was found, which was repaired by packing the pouch with muscle and fibrin glue. Clinical improvement was observed shortly after surgery, and postoperative imaging revealed the disappearance of the CSF leakage.

CONCLUSIONS

T-SLIP MRI may provide useful information on the flow dynamics of CSF in SIH patients due to high-flow leakage. However, further experience is required to assess its sensitivity and specificity as an imaging modality for identifying CSF leakage points.

Delayed Dural Leak Following Posterior Spinal Fusion for Idiopathic Scoliosis Using All Posterior Pedicle Screw Technique

BACKGROUND

In pediatric patients, pedicle screws are malpositioned 5% to 15% of the time. Complications associated with malpositioned screws are infrequently reported in the literature. We present a series of adolescent idiopathic scoliosis (AIS) patients who presented in a delayed manner with positional headache and chronic dural leak adjacent to the pedicle screw tract.

METHODS

Scoliosis databases at 2 centers were reviewed, and cases of delayed positional headaches following posterior spinal fusion for AIS were identified. Demographic and clinical data were collected.

RESULTS

Of 322 patients, 4 patients presented with positional headaches at a mean of 12.8 weeks following posterior spinal fusion surgery for AIS, with an interval time to diagnosis of 5 months. Computed tomographic myelogram demonstrated severe pedicle screw malposition in 1 patient, and minimal malposition in 3 patients (<2 mm violation). The patients had delayed presentation with positional headaches secondary to dural leak. All patients successfully underwent revision surgery with repair of the dural leak. At the time of latest follow-up, all patients are asymptomatic.

CONCLUSIONS

Pedicle screw malposition can result in dural leaks. Patients may present in a delayed manner with positional headaches and an acquired Chiari malformation. Clinical suspicion should prompt imaging of the brain or cervical spine followed by computed tomographic myelogram to determine site of leak. This is a rare complication from pedicle screw malposition.

LEVELS OF EVIDENCE

Level IV-case series.

Spontaneous intracranial hypotension caused by cervical CSF fistulae mimicking subarachnoid haemorrhage - a case report

We describe an unusual and rarely documented site of SIH supported by clear radiological evidence: a case of spontaneous cerebrospinal fluid (CSF) fistulae involving the C7 and C8 nerve root sheaths, presenting with sudden onset headache and requiring surgical intervention to seal the leaks. Investigations confirmed the leaks and the typical MRI findings of meningeal enhancement, which were resolved after surgery.

Epidural blood patch for spontaneous intracranial hypotension with chronic subdural haematoma: A case report and literature review

Spinal leakage of cerebrospinal fluid (CSF) is considered to be the primary cause of spontaneous intracranial hypotension (SIH). Subdural haematoma (SDH) is a serious complication of SIH. This current report presents a case of bilateral SDH with SIH that was treated with epidural blood patching (EBP). A 43-year-old male complained of experiencing orthostatic headaches for 2 months without neurological signs. The patient worsened in a local hospital and was transferred to the Sir Run Run Hospital. Brain computed tomography showed bilateral SDH with a midline shift. The patient underwent emergency trephination in the left frontal temporal region. Postoperative magnetic resonance myelography showed a CSF leak originating at the T11–L2 level. As a consequence of clinical deterioration of the patient, EBP was subsequently performed at the T12–L1 level. The headache was rapidly relieved and later the SDH was completely absorbed. This case report and literature review aims to remind clinicians that SIH can cause SDH and that EBP is a viable treatment option.

The Relief of Unilateral Painful Thoracic Radiculopathy without Headache from Remote Spontaneous Spinal Cerebrospinal Fluid Leak

Spontaneous intracranial hypotension (SIH) caused by spontaneous spinal cerebrospinal fluid (CSF) leaks produces orthostatic headaches. Although upper arm pain or paresthesia is reportedly associated with SIH from spontaneous spinal CSF leak in the presence of orthostatic headache, low thoracic radicular pain due to spontaneous spinal CSF leak unassociated with postural headache is extremely rare. We report a 67-year-old female who presented with chronic, positional radicular right T11 pain. Computed tomography myelography showed a spontaneous lumbar spinal CSF leak at L2-3 and repeated lumbar epidural blood patches significantly alleviated chronic, positional, and lower thoracic radiculopathic pain. The authors speculate that a chronic spontaneous spinal CSF leak not severe enough to cause typical orthostatic headache or epidural CSF collection may cause local symptoms such as irritation of a remote nerve root. There might be considerable variabilities in the clinical features of SIH which can present a diagnostic challenge.

Efficacy of epidural blood patch with fibrin glue additive in refractory headache due to intracranial hypotension: preliminary report

Background

Injection of fibrin glue mixed with blood into the epidural space to reliably and effectively treat medically refractory orthostatic headache caused by spinal cerebrospinal fluid (CSF) leaks and subsequent intracranial hypotension has recently been described. The study described in this article utilizes an analogous technique to gauge the therapeutic reproducibility of this novel technique.

Methods

Eight patients with medically refractory headache resulting from intracranial hypotension caused by spinal CSF leaks received epidural injections of combined fibrin glue, autologous blood, and Isovue contrast at the L1—2 vertebral level using intermittent fluoroscopic guidance. Pre-procedure, 1-week post-procedure, and 3-month post-procedure headache pain scores were collected and used for comparison.

Results

Three out of 8 patients reported relief at 1 week, although 1 of these 3 patients had returned to their baseline pain intensity at 3 months. Four patients reported no change at 1 week, though 2 of these patients had reduction of their chronic headache pain at 3 months. A single patient reported increased pain 1 week after the procedure, which persisted at 12 weeks. Overall, 4 out of the 8 patients had decreased pain scores at 3-month follow-up.

Conclusions

We did not achieve a similar frequency of headache resolution as reported in prior original studies. However, a subset of patients did appear to receive substantial benefit from the combined fibrin glue-blood patching procedure. This technique may prove to be useful in medically refractory cases, including those patients who continue to have symptoms despite the prior administration of conventional epidural blood patches.

Treatment strategy for cerebral hypotension caused by spontaneous cerebrospinal fluid leaks

OBJECTIVE

Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare (5 per 100,000 per year). Treatment generally consists of conservative therapy or interventional therapy with epidural blood patching. Surgical treatment is conducted rarely, usually in cases when conservative or interventional treatment has failed. The aim of our case series was to assess the clinical outcome after surgery.

METHODS

Our clinical database was reviewed for patients with spontaneous spinal CSF leaks who underwent surgical exploration between 2010 and 2013. Etiology, symptoms, preoperative imaging, type of required surgical method, intraoperative findings, and clinical outcome were reported.

RESULTS

We identified five patients with a mean age of 62 years with spontaneous spinal CSF leaks who were treated surgically. Two patients received surgery after failure of interventional treatment. The origin of the CSF leak could be identified intraoperatively in three cases. Surgical technique in all cases consisted of an interlaminar fenestration or hemilaminectomy and a complete foraminotomy to explore the thecal sack and the exiting nerve roots and identify the CSF leak. After surgery, the preoperative symptoms improved in all patients. In one case, there was a relapse after 4 weeks.

CONCLUSIONS

Preoperative identification of a CSF leak with MRI was positive in only one case. In all other cases, a post-myelography CT had to be performed. In all cases, the preoperative symptoms improved after surgery. Surgical treatment is an effective treatment of spontaneous cerebrospinal fluid leaks in cases of refractory symptoms after failed conservative or interventional treatment.

Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature

PURPOSE

In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported.

METHODS

Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed.

RESULTS

The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm.

CONCLUSIONS

Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.

Hemodynamics in the Circle of Willis with Internal Carotid Artery Stenosis under Cervical Rotatory Manipulation: A Finite Element Analysis

Background

The circle of Willis (CoW) plays an important role in cerebral collateral circulation. The hemodynamics changes in the CoW have usually been associated with the internal carotid artery (ICA) stenosis, but whether rotatory manipulation will affect it remains unknown.

Material/Methods

In this study we attempted to analyze the influence of rotatory manipulation on the hemodynamics in the CoW in models with or without ICA stenosis by means of finite element analysis. For this purpose, the CoW was reasonably simplified and a fluid-solid coupling 3D finite element model was created by using MIMICS10.0 and ANSYS14.5. The healthy (without stenosis) and the diseased (ratios of stenosis include 15%, 30%, 45%, 60%, 70%, 80%, and 90%) situations were simulated. A remote displacement of 60° was applied at a distal ICA (the right ICA was chosen here) to imitate the rotatory manipulation. Blood flow was then monitored at the anterior communicating artery (ACoA) and posterior communicating arteries (PCoA).

Results

Before the conduction of rotatory manipulation, blood flow changed significantly only when the stenosis ratio was increased to more than 70%, and the situation did not have significant difference after the application of remote displacement except the model with stenosis ration of 90%.

Conclusions

The result suggests that the rotatory manipulation does not have an obvious influence on the blood flow in the CoW when the stenosis of ICA is less than 90%, and this kind of manipulation is suggested to be a safe technique in most of the clinical applications.

[Cerebrospinal fluid leakage. Indications, technique and results of treatment with a blood patch]

BACKGROUND

In most cases cerebrospinal fluid (CSF) leaks are iatrogenic and caused by medical interventions, such as lumbar puncture, peridural anesthesia and surgical interventions on the spine, However, spontaneous cerebral hypotension is currently detected more frequently due to improvements in diagnostic possibilities but often the cause cannot be clarified with certainty.

METHODS

There are various diagnostic tools for confirming the diagnosis and searching for the site of CSF leakage, such as postmyelography computed tomography (postmyelo-CT), indium(111) radioisotope cisternography and (myelo) magnetic resonance imaging (MRI), which show different sensitivities. In accordance with own experience native MRI with fat-saturated T2-weighted sequences is often sufficient for diagnosing CSF leakage and the site. For the remaining cases an additional postmyelo-CT or alternatively myelo-MRI is recommended. In some patients with spontaneous cranial hypotension multiple CSF leaks are found at different spinal levels. The main symptom in most cases is an orthostatic headache. While post-puncture syndrome is self-limiting in many cases, spontaneous CSF leakage usually requires blood patch therapy. A lumbar blood patch can be safely carried out under guidance by fluoroscopy. In the case of a cervical or dorsal blood patch, CT guidance is recommended, which ensures epidural application of the blood patch and minimizes the risk of damaging the spinal cord. Despite a high success rate at the first attempt with a blood patch of up to 85%, some cases require repeating the blood patch. A targeted blood patch of a CSF leak should generally be favoured over a blindly placed blood patch; nevertheless, if a CSF leak cannot be localized by CT or MRI a therapeutic attempt with a lumbar blood patch can be carried out. After a successful blood patch intracranial hygromas and pachymeningeal enhancement in the head show fast regression; however, epidural hygromas of the spine can persist for a period of several months, even though patients are already free of symptoms.

CONCLUSION

In total, blood patch therapy is a safe and technically relative simple method with a high success rate. Therefore, it represents the therapy of choice in patients with spontaneous cerebrospinal fluid leakage as well as in cases of post-lumbar puncture syndrome refractory to conservative therapy.

Spontaneous intracranial hypotension manifesting as a unilateral subdural hematoma with a marked midline shift

Spontaneous intracranial hypotension (SIH) is a syndrome in which hypovolemia of the cerebrospinal fluid (CSF) results in various symptoms. Although its prognosis is usually benign, cases with a rapid neurologic deterioration resulting in an altered mental status have been reported. One of the characteristic radiographic findings in such cases is the presence of bilateral accumulation of subdural fluid (hematoma/hygroma). When SIH-related subdural hematoma is present only unilaterally with a concomitant midline shift, making an accurate diagnosis may be challenging, and inadvertent hematoma evacuation may result in further neurologic deterioration. We report a 58-year-old woman with an altered mental status who had visited a local hospital and in whom a brain CT showed a unilateral subdural hematoma with a marked midline shift. She was referred to our department because of her neurologic deterioration after hematoma evacuation. A CT myelography revealed a massive CSF leakage in the entire thoracic epidural space. She made a full neurologic recovery following blood patch therapy. Our case is unique and educational because the suspicion for SIH as an underlying cause of subdural hematoma is warranted in nongeriatric patients not only with bilateral but also unilateral lesions. An immediate search for CSF leakage may be important in cases with failed hematoma evacuation surgery.

Ultrafast dynamic computed tomography myelography for the precise identification of high-flow cerebrospinal fluid leaks caused by spiculated spinal osteophytes

OBJECT

Precise localization and understanding of the origin of spontaneous high-flow spinal CSF leaks is required prior to targeted treatment. This study demonstrates the utility of ultrafast dynamic CT myelography for the precise localization of high-flow CSF leaks caused by spiculated spinal osteophytes.

METHODS

This study reports a series of 14 patients with high-flow CSF leaks caused by spiculated spinal osteophytes who underwent ultrafast dynamic CT myelography between March 2009 and December 2010. There were 10 male and 4 female patients, with an average age of 49 years (range 37–74 years). The value of ultrafast dynamic CT myelography in depicting the CSF leak site was qualitatively assessed.

RESULTS

In all 14 patients, ultrafast dynamic CT myelography was technically successful at precisely demonstrating the site of the CSF leak, the causative spiculated osteophyte piercing the dura, and the relationship of the implicated osteophyte to adjacent structures. Leak sites included 3 cervical, 11 thoracic, and 0 lumbar levels, with 86% of the leaks occurring from C-5 to T-7. Information obtained from the ultrafast dynamic CT myelogram was considered useful in all treated CSF leaks.

CONCLUSIONS

Spinal osteophytes piercing the dura are a more frequent cause of high-flow CSF leaks than previously recognized. Ultrafast dynamic CT myelography adds value beyond standard dynamic myelography or digital subtraction myelography in the diagnosis and anatomical characterization of high-flow spinal CSF leaks caused by these osteophytes. This information allows for appropriate planning for percutaneous or surgical treatment.

Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy

PURPOSE OF REVIEW

To illustrate clinical presentations, imaging findings, and diagnostic and therapeutic approaches associated with various conditions of intracranial hypotension.

RECENT FINDINGS

Intracranial hypotension occurs spontaneously, following (lumbar) dural puncture, accidental dural opening, or excessive surgical cerebrospinal fluid drainage. The typical clinical manifestation - orthostatic headache - may be masqueraded by atypical clinical findings, including coma, frontotemporal dementia, leptomeningeal hemosiderosis-associated symptoms, and others. MRI signs are highly specific, but the imaging strategy to search for spinal cerebrospinal fluid leaks (none, computed tomography myelography, magnetic resonance myelography with gadolinium, digital subtraction myelography) is a matter of debate. The same is true for the mode of treatment (bed rest, blind, fluoroscopy or computed tomography-guided epidural blood patching, fibrin patching, surgery).

SUMMARY

Clinical presentation as well as diagnostic and therapeutic approaches in intracranial hypotension are very heterogenous.

Symptomatic pneumocephalus associated with lumbar dural tear and reverse trendelenburg positioning: a case report and review of the literature

Symptomatic pneumocephalus is a rare complication of degenerative lumbar spine surgery. This is a case report of a patient who developed transient diplopia associated with pneumocephalus following lumbar spine surgery complicated by a dural tear. The diplopia improved as the pneumocephalus resolved. Factors involved in the development of pneumocephalus include an unintended durotomy and intraoperative reverse Trendelenburg positioning that was utilized to decrease the risk of postoperative vision loss. When encountering cerebrospinal fluid (CSF) leakage intraoperatively, spine surgeons should level the operating table until closure of the dural defect to prevent potential complications associated with pneumocephalus. If postoperative patients complain of severe headaches or display a focal cranial neurologic deficit, then a computed tomography (CT) scan of the brain should be ordered and evaluated. Consulting neurologists should be aware of the circumstances surrounding this rare complication.

Feasibility of placement of an anterior cervical epidural blood patch for spontaneous intracranial hypotension

The dorsal epidural blood patch is a commonly used management technique for spontaneous intracranial hypotension from a dural CSF leak, but it may be less efficacious for cervical or ventral leaks. We report the technique of placing an anterior cervical blood patch for a large cervical ventral leak. To our best knowledge, this approach has not been reported. In the appropriately selected patient, an anterior cervical epidural blood patch may be safely used.

Intracranial hypotension caused by anterior cervical CSF leak alleviated by an epidural blood patch [corrected]

We present a case in which a thoracocervical epidural blood patch was used to treat an anteriorly situated cerebrospinal fluid leak following 2 failed blood patches in the lumbar region. The challenge in identifying the source of the leak, deteriorating health of the patient, and risks from the procedure, contributes to the uniqueness of this case.

Symptomatic postlaminectomy cerebrospinal fluid leak treated with 4-dimensional ultrasound-guided epidural blood patch

BACKGROUND

A persistent cerebrospinal fluid leak after spinal surgery can be associated with both meningitis and/or pneumocephalus. Therefore, early active intervention is recommended with surgical exploration, lumbar subarachnoid drain, and less commonly epidural blood patch. In the absence of a ligamentum flavum, the use of high-resolution ultrasound (US) spine imaging enables real-time advancement of a Tuohy needle towards the dura and the precise injection of blood to cover the dural defect.

METHODS

Six patients, after lumbar spine surgery with instrumentation and primary closure was complicated by incidental dural tears, developed severe symptomatic headaches that failed conservative therapy. All patients underwent US-guided epidural blood patch. Precise needle advancement to the dura was observed with US guidance, and 4-dimensional US scanning was used to confirm the expansion of blood over the dura in real time.

RESULTS

All patients had symptomatic relief of their headaches and successful treatment of dural leaks using US-guided blood patch.

CONCLUSIONS

Real-time US guidance allowed accurate positioning of the Tuohy needle and deposition of the epidural blood patch in the setting of a surgically removed ligamentum flavum. Further investigations are needed to confirm that an US-guided epidural blood patch may offer reliable symptomatic relief to postsurgical persistent cerebrospinal fluid leak and may serve as an intermediate step along a spectrum between conservative initial management and surgical reexploration.

Surgical treatment of spontaneous intracranial hypotension secondary to degenerative cervical spine pathology: a case report and literature review

OBJECTIVE AND IMPORTANCE

A rare cause of intracranial hypotension is leakage of cerebrospinal fluid (CSF) through a dural breach from degenerative cervical spine pathology. To our knowledge there have been only four cases described in the English literature. Treatment is challenging and varies from case to case, with complete symptom resolution reported for only one patient. Herein we review the literature and describe our surgical management of a 46-year-old woman with symptomatic intracranial hypotension from the penetration of the cervical thecal sac.

CLINICAL PRESENTATION

The patient presented with a 3-month history of progressive orthostatic headaches. Magnetic resonance imaging demonstrated bilateral subdural hematomas and pachymeningeal gadolinium enhancement. An anterior epidural CSF collection commencing at a C4-5 calcified disc protrusion and osteophyte was evident on a computed tomography spinal myelogram.

INTERVENTION

After three unsuccessful lumbar blood patches, we elected to attempt surgical removal of the causative pathology with exposure and primary closure of the dural defect by anterior cervical discectomy as described previously. After resection of the disc-osteophyte complex and dural exposure, immediate high volume egression of CSF mixed with blood at the surgical site. The dural defect was not visible but CSF egression promptly ceased. Cervical corpectomy for greater exposure and primary repair of the defect has been described, but we considered this unwarranted and felt the intraoperative blood collection formed a local blood patch. A collagen dural substitute membrane was inserted through the discectomy space for reinforcement.

CONCLUSION

Two months after this novel surgical blood patch procedure the patient was asymptomatic and follow-up imaging demonstrated complete resolution.

CT-guided percutaneous translaminar approach for blood patching: case report and technical note

In this article the authors describe a novel technique for performing epidural blood patch (EBP) by percutaneous CT-guided translaminar approach in challenging cases where interlaminar approach is not possible. A 24-year-old woman with medical history of multiple spinal surgeries and instrumentations for the treatment of scoliosis, presented 3 months post-operatively with acute and severe orthostatic headaches that began 1 week after surgery. Neurological examination was normal. Brain magnetic resonance imaging (MRI) showed mild thickening and contrast enhancing in the bilateral dura. Computed tomography (CT) myelography revealed CSF leakage in the level of T3 vertebra. EBP was attempted using fluoroscopic and then CT guidance; however, despite multiple attempts, the epidural space could not be accessed through the interlaminar route due to extensive instrumentation of the spine and profound structural bony abnormalities. EBP was performed successfully via a CT-guided translaminar approach using an Ostycut trephine needle (Angiomed(®)/Bard, Karlsruhe), without complications.

Spontaneous intracranial hypotension due to intradural thoracic osteophyte with superimposed disc herniation: report of two cases

Spontaneous intracranial hypotension (SIH) is a clinical syndrome in which absolute or relative hypovolemia of the cerebrospinal fluid (CSF) results in various neurological symptoms. The etiology of spontaneous CSF leaks often remains unknown. However, it is believed that the most common cause is the fragility of spinal meninges at the level of radicular nerve root sleeve. These tears can be spontaneous (primary) or secondary. Spinal pathologies can cause this tear with resultant CSF leak and SIH, which include spinal trauma, degenerative diseases and spinal surgery. Uncommonly, SIH is developed by osteophyte with disc herniation without any other pathology. In this article, we reported two cases of SIH secondary to spinal dural tear due to intradural thoracic osteophyte with superimposed disc herniation, with the absence of other pathologies, which were treated successfully with epidural blood patch (EBP).

Resolution of syringohydromyelia with targeted CT-guided epidural blood patching

In the scientific literature, syringohydromyelia has only rarely been reported in association with spontaneous intracranial hypotension. Management of the syringohydromyelia in these patients has heretofore involved relatively invasive surgical procedures. The authors report the first case of syringohydromyelia in the setting of intracranial hypotension successfully treated with CT-guided epidural blood patches. This case is important in that it represents a potential minimally invasive treatment strategy. Furthermore, the case also highlights the need to consider spontaneous intracranial hypotension when clinically appropriate as a cause of syrinx in patients with cerebellar tonsillar ectopia, in whom the lesion might otherwise be misclassified as a Chiari I malformation. Finally, the responses to the various attempted treatments offer insight into the pathophysiology of this syringohydromyelia, which may differ from classical models of syrinx formation.

Cranial nerve III palsy resulting from intracranial hypotension caused by cerebrospinal fluid leak after paraspinal tumor resection: etiology and treatment options

BACKGROUND CONTEXT

Intracranial hypotension typically occurs spontaneously. Acquired or secondary intracranial hypotension is less common but has been reported after spinal procedures, such as lumbar puncture. Cranial nerve (CN) III palsy is a rare sequela of intracranial hypotension. There are currently no established or standard interventions to treat intracranial hypotension.

PURPOSE

To describe a case of delayed CN III palsy resulting from intracranial hypotension because of a spinal cerebrospinal fluid (CSF) leak occurring during resection of a paraspinous tumor.

STUDY DESIGN

Case report.

METHODS

A 41-year-old woman underwent resection of a large thoracic schwannoma complicated by dural tear. Postoperatively, the patient was neurologically normal. She subsequently became acutely unresponsive and required reintubation. She awakened with intermittent headaches and was noted to have a right ptosis, which progressed to a complete right CN III palsy.

RESULTS

Initial head computed tomography showed evidence of a small, right-sided subdural hematoma. Magnetic resonance imaging (MRI) of the brain showed diffuse leptomeningeal enhancement and crowding of the foramen magnum consistent with intracranial hypotension. The patient's symptoms were treated successfully with flat bed rest. She fully recovered by time of discharge and at 6-month follow-up was neurologically normal.

CONCLUSIONS

Spinal surgery complicated by CSF leak is a potential cause of intracranial hypotension. Although most commonly associated with positional headaches, intracranial hypotension can cause uncommon symptoms, including acute mental status changes and CN deficits. Symptoms highly suspicious for intracranial hypotension accompanied by MRI of the brain are important for establishing a diagnosis of intracranial hypotension. Conservative treatment should be considered before attempting invasive intervention. As in the case presented, simple bed rest was a successful treatment option.