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Kapan A, Waldhör T, Wöber C. Assessing the effects of spontaneous intracranial hypotension on quality of life, work ability and disability. Wien Klin Wochenschr 2024:10.1007/s00508-024-02423-4. [PMID: 39225762 DOI: 10.1007/s00508-024-02423-4] [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: 04/02/2024] [Accepted: 07/27/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH), characterized by headaches due to cerebrospinal fluid leaks or low pressure, is a challenging condition to diagnose and treat and affects the quality of life. METHODS An 8‑week online survey was conducted to assess the impact of SIH on symptoms, sociodemographics and quality of life. The cohort was comprised of patients who had a self-reported diagnosis of SIH and were divided into two groups: those with radiological evidence of SIH and those with clinical suspicion but no radiological evidence. Mental health and disability were evaluated using the Depression, Anxiety and Stress Scale-21 (DASS-21) and the Henry Ford Hospital Headache Disability Inventory (HDI). RESULTS A total of 86 participants were included in the study, 59 with radiological evidence and 27 without. Most participants were female (84.9%) with a mean age of 44.8 years. Orthostatic headache was more common in participants without radiological evidence (74.1% vs. 42.4%). The severity in those with radiological evidence was 27.1% mild, 27.1% moderate, 30.5% severe and 15.3% extremely severe, while those without had 7.4% mild, 18.5% moderate, 63.0% severe and 11.1% extremely severe headaches. Mental health assessment using the DASS-21 scale showed that 77.9% of all participants reported signs of depression, 96.5% reported anxiety and 89.5% reported stress. The HDI showed 2.3% total disability, 40.7% severe, 19.8% moderate and 37.2% mild. The impact on employment was significant: 15.1% were able to work full-time, 48.8% part-time, 30.2% were unable to work and 5.8% retired early due to SIH. CONCLUSION The study demonstrates the broad impact of SIH affecting physical health, mental well-being, and socioeconomic status, and calls for multifaceted and robust management approaches to address its complex effects on patients.
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Affiliation(s)
- Ali Kapan
- Center for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Kinderspitalgasse 15, 1090, Vienna, Austria.
| | - Thomas Waldhör
- Center for Public Health, Department of Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Christian Wöber
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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Tay ASMS, Maya MM, Schievink WI. Spontaneous intracranial hypotension mimicking iatrogenic spinal cerebrospinal fluid leaks. Headache 2024. [PMID: 39221817 DOI: 10.1111/head.14826] [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: 03/20/2024] [Revised: 07/29/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To raise awareness that patients with persistent post-dural puncture headache should be considered for evaluation of spontaneous cerebrospinal fluid (CSF) leak. BACKGROUND Spontaneous intracranial hypotension (SIH) due to a spinal CSF leak may occur following more-or-less trivial traumatic events. We report our experience with spontaneous spinal CSF leaks that occur following percutaneous or open spine procedures, a potential source of diagnostic confusion. METHODS In a retrospective cohort study, using a prospectively maintained database of patients with SIH, we identified all new patients evaluated between January 1, 2022, and June 30, 2023, who were referred for evaluation of an iatrogenic spinal CSF leak but were found to have a spontaneous spinal CSF leak. RESULTS Nine (4%) of the 248 patients with SIH were originally referred for evaluation of an iatrogenic spinal CSF leak. The spinal procedures included epidural steroid injections, laminectomies, epidural anesthesia, and lumbar puncture. Brain magnetic resonance imaging (MRI) showed changes in intracranial hypotension in seven of the nine patients (78%). The spontaneous CSF leak was found to be at least five levels removed from the spinal procedure in all patients. CONCLUSIONS A spontaneous spinal CSF leak should be suspected in patients with recalcitrant orthostatic headaches following a spinal procedure, even if symptoms of the leak occur within hours of the spinal procedure and especially if brain MRI is abnormal.
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Affiliation(s)
| | - Marcel M Maya
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Wouter I Schievink
- Department of Neurosurgery, Cedars Sinai Medical Center, Los Angeles, California, USA
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Lin PT, Hseu SS, Fuh JL, Lirng JF, Chen SP, Chen WT, Wang SJ, Wang YF. Sex differences in the clinical manifestations and treatment outcomes in a large cohort of spontaneous intracranial hypotension. Headache 2024. [PMID: 39221780 DOI: 10.1111/head.14816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To determine sex differences in clinical profiles and treatment outcomes in patients with spontaneous intracranial hypotension. BACKGROUND Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether males and females should be managed differently. METHODS This was a cohort study of consecutive patients with spontaneous intracranial hypotension enrolled from a medical center. Medical records and imaging findings were reviewed. The outcome of treatment responses to epidural blood patches and risks of subdural hematoma were measured. RESULTS In total, 442 patients with spontaneous intracranial hypotension (165 males, 277 females) were included in the analysis. Males were more likely to have a delayed (>30 days) initial presentation than females (32.1% [53/165] vs. 19.9% [55/277], p = 0.004), and males were less likely to have nausea (55.8% [92/165] vs. 67.1% [186/277], p = 0.016), vomiting (43.0% [71/165] vs. 54.2% [150/277], p = 0.024), photophobia (9.7% [16/165] vs. 17.0% [47/277], p = 0.034), and tinnitus (26.7% [44/165] vs. 39.7% [110/277], p = 0.005) compared with females despite comparable radiologic findings. Among the 374 patients treated with epidural blood patches, males were more likely to be nonresponders to the first epidural blood patch (58.0% [80/138] vs. 39.0% [92/236], OR = 2.2, 95% CI = 1.4-3.3, p < 0.001). Males were at a higher risk of having subdural hematoma (29.7% [49/165] vs. 10.8% [30/277], OR = 3.5, 95% CI = 2.1-5.8, p < 0.001). Among patients with subdural hematoma, males had greater thickness (12.8 ± 4.3 vs. 8.1 ± 5.9 mm, p < 0.001) and were more likely to receive surgical drainage (55.1% [27/49] vs. 10.0% [3/30], OR = 11.0, 95% CI = 3.0-41.3, p < 0.001) than females. CONCLUSION In the present study, spontaneous intracranial hypotension in males was characterized by a delayed presentation, poorer response to the first epidural blood patch, and a higher risk of subdural hematoma. Caution should be exercised in the management of males with spontaneous intracranial hypotension. The generalizability of the findings needs to be further confirmed.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Shya Hseu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Ministry of Health and Welfare Keelung Hospital, Keelung, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Hudson JS, Fernandes-Cabral D, Agarwal P, Legarreta A, Schulien A, Deng H, Agarwal V, Okonkwo DO. Anterior Thoracic Discectomy and Fusion for Symptomatic Ventral Bone Spur Associated Type I Cerebrospinal Fluid Leak: A Technical Report and Operative Video. Global Spine J 2024; 14:1920-1923. [PMID: 36869642 DOI: 10.1177/21925682231161303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
STUDY DESIGN Technical Report. OBJECTIVE Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine. METHODS In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect. RESULTS The patient had complete resolution of his preoperative symptoms after primary repair. CONCLUSIONS In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks.
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Affiliation(s)
- Joseph S Hudson
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Fernandes-Cabral
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Prateek Agarwal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew Legarreta
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anthony Schulien
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vikas Agarwal
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh PA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Callen AL, Han L, Pisani Petrucci SL, Andonov N, Lennarson P, Birlea M, O'Brien C, Wilhour D, Anderson A, Bennett JL, Carroll IR. Patterns of clinical and imaging presentations in patients with spontaneous intracranial hypotension due to spinal cerebrospinal fluid venous fistula: A single-center retrospective cross-sectional study. Headache 2024; 64:939-949. [PMID: 39129307 DOI: 10.1111/head.14805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/29/2024] [Accepted: 07/01/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVE To identify distinct clinical or imaging subtypes of spontaneous intracranial hypotension (SIH) due to spinal cerebrospinal fluid (CSF) venous fistula (CVF). BACKGROUND Spontaneous intracranial hypotension is classically understood to present clinically with an orthostatic headache and stereotyped brain magnetic resonance imaging (MRI) findings; however, most prior literature examining clinical and brain MRI features of SIH has focused on all types of spinal CSF leaks concurrently. This study aimed to evaluate whether data support the possibility of internally consistent subtypes based on brain imaging features and clinical symptoms analogous to those seen in primary headache syndromes. METHODS This retrospective cross-sectional single-institution study included 48 consecutive patients meeting the International Classification of Headache Disorders, 3rd edition criteria for SIH due to CVF. Clinical symptoms, pre-treatment brain MRI, and symptom duration were analyzed. Clinical and MRI data were analyzed to identify patterns and associations between symptoms and imaging findings. RESULTS A total of 20 males and 28 females were evaluated, with a mean (standard deviation) age of 61 (10) years. In all, 44/48 (92%) patients experienced headaches, though 18/48 (40%) did not endorse relief when flat, including six of the 48 (13%) with worsening symptoms when flat. In all, 19/48 (40%) patients reported at least one migraine symptom, and six of the 48 (13%) presented with at least one migraine symptom and had no relief when flat. Clinical symptoms clustered primarily into a "classic" presentation consisting of relief when flat, occipital head pain, comorbid neck pain, a pressure/throbbing headache quality, and an "atypical" presentation that was characterized by having several differences: less relief when flat (nine of 22 (41%) vs. 20/23 (87.0%), p = 0.002; odds ratio [OR] 0.110, 95% confidence interval [CI] 0.016-0.53), more frontal head pain (14/22 (64%) vs. one of 23 (4%), p < 0.001; OR 35.0, 95% CI 4.2-1681.0), less neck pain (two of 21 (4.5%) vs. nine of 13 (69.6%), p < 0.001; OR 0.023, 95% CI 0.0005-0.196), and more stabbing/sharp headache quality (nine of 22 (41%) vs. two of 23 (9%), p = 0.017; OR 7.0, 95% CI 1.18-75.9). Brain MRI findings clustered into three groups: those presenting with most imaging findings of SIH concurrently, those with brain sag but less pachymeningeal/venous engorgement, and those with pachymeningeal/venous engorgement but less brain sag. CONCLUSION This study highlights the clinical and imaging diversity among patients with SIH due to CVF, challenging the reliance on classic orthostatic headache alone for diagnosis. The findings suggest the existence of distinct SIH subtypes based on clinical and imaging presentations, underscoring the need for comprehensive evaluation in patients with suspected CVF. Future research should further elucidate the relationship between clinical symptoms and imaging findings, aiming to refine diagnostic criteria and enhance understanding of SIH's pathophysiology.
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Affiliation(s)
- Andrew L Callen
- Department of Radiology, Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lichy Han
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Samantha L Pisani Petrucci
- Department of Radiology, Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nadya Andonov
- Department of Radiology, Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Peter Lennarson
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marius Birlea
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Chantal O'Brien
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Danielle Wilhour
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Abigail Anderson
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeffrey L Bennett
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Programs in Neuroscience and Immunology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ian R Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
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Onuoha O, Brown K, Jiang Y, Orlando B. Non-targeted serial epidural blood patches for the treatment of intracranial hypotension headache during late pregnancy: a case report. Int J Obstet Anesth 2024; 59:103996. [PMID: 38719763 DOI: 10.1016/j.ijoa.2024.103996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 04/08/2024] [Indexed: 07/07/2024]
Abstract
Intracranial hypotension can cause persistent and severe orthostatic headaches. It is often the result of cerebrospinal fluid leakage secondary to iatrogenic causes. It can also happen spontaneously. Diagnosing and managing severe orthostatic headaches associated with intracranial hypotension can be challenging, particularly during late pregnancy. This case describes a parturient at 30 weeks' gestation who presented with severe headaches due to intracranial hypotension caused by dural defects and cerebrospinal fluid venous fistula. She was managed with serial non-targeted epidural blood patching as a bridging remedy. This allowed further fetal maturity before delivery and definitive management of the dural leakage after delivery.
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Affiliation(s)
- O Onuoha
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - K Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Y Jiang
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - B Orlando
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA
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Benson JC, Mark IT, Madhavan AA, Johnson-Tesch B, Diehn FE, Carr CM, Kim DK, Brinjikji W, Verdoorn JT. Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks? Neuroradiol J 2024; 37:468-472. [PMID: 38525966 PMCID: PMC11366203 DOI: 10.1177/19714009241242645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH. MATERIALS AND METHODS A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated. RESULTS 174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky). CONCLUSIONS Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.
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Affiliation(s)
| | - Ian T Mark
- Department of Radiology, Mayo Clinic, USA
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Yuzkan S, Benlice T, Guzelbey T, Yilmaz MF, Ozbey O, Sam Ozdemir M, Balsak S, Ozkiziltan U, Altunkaynak Y, Kilickesmez O, Kocak B. Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening. Neuroradiology 2024; 66:1335-1344. [PMID: 38658472 DOI: 10.1007/s00234-024-03359-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/13/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility. METHODS In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen's kappa statistics, interobserver agreement was assessed. RESULTS In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39). CONCLUSION The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.
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Affiliation(s)
- Sabahattin Yuzkan
- Department of Radiology, Koc University Hospital, Zeytinburnu, 34010, Istanbul, Turkey
| | - Tahsin Benlice
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Tevfik Guzelbey
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Mehmed Fatih Yilmaz
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Oner Ozbey
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Merve Sam Ozdemir
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Serdar Balsak
- Department of Radiology, Bezmialem Vakif University Hospital, Istanbul, Turkey
| | - Uluc Ozkiziltan
- Department of Radiology, Ege University School of Medicine, Izmir, Turkey
| | - Yavuz Altunkaynak
- Department of Neurology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Ozgur Kilickesmez
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Burak Kocak
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey.
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Kurian L, Dagra A, Lucke-Wold B. Commentary: Development and Clinical Validation of a Hook Effect-Based Lateral Flow Immunoassay Sensor for Cerebrospinal Fluid Leak Detection. Neurosurgery 2024; 95:e39-e40. [PMID: 38578089 DOI: 10.1227/neu.0000000000002917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 04/06/2024] Open
Affiliation(s)
- Lisa Kurian
- College of Medicine, Florida State University, Tallahassee , Florida , USA
| | - Abeer Dagra
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Brandon Lucke-Wold
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
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Zhou Y, Tong C. Spontaneous intracranial hypotension in a patient without corpus callosum: A case report. Medicine (Baltimore) 2024; 103:e39090. [PMID: 39058873 PMCID: PMC11272263 DOI: 10.1097/md.0000000000039090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
RATIONALE Spontaneous intracranial hypotension (SIH) is a well-established condition typically presenting with disabling orthostatic headache. Corpus callosum agenesis (CCA) is one of the most common human brain malformations with a wide spectrum of associated malformations, chromosomal abnormalities, and clinical syndromes. PATIENT CONCERNS A 53-year-old woman presented with recurrent orthostatic headache for about 1 month. The head computed tomography examination of the patient showed CCA and the initial pressure of subsequent lumbar puncture was only 5 centimeters cerebrospinal fluid. Magnetic resonance imaging examination confirmed CCA with gray matter heterotopia. DIAGNOSIS The final diagnose was SIH related headache with CCA. INTERVENTION The patient's symptom improved after oral hydration, intravenous fluids, and bed rest. OUTCOME Favorable outcome was observed. LESSONS Although this co-occurrence of SIH and CCA is probably coincidental, this finding suggests that the developmental malformations of the brain may lead to structural changes in brain tissue or disturbances in cerebrospinal fluid production and reflux, resulting in pathological changes over time.
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Affiliation(s)
- Yang Zhou
- Department of Neurology, Shaoxing Second Hospital, Shaoxing, Zhejiang, China
| | - Chenglin Tong
- Department of Emergency Internal Medicine, Shaoxing Second Hospital, Shaoxing, Zhejiang, China
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11
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Schievink WI, Maya MM, Nuño M. De Novo Formation of Idiopathic Spinal Cord Herniation. AJNR Am J Neuroradiol 2024:ajnr.A8338. [PMID: 39054292 DOI: 10.3174/ajnr.a8338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/24/2024] [Indexed: 07/27/2024]
Abstract
We investigated whether idiopathic spinal cord herniation is a congenital or acquired condition and undertook a study to determine the risk of developing iSCH in patients with persistent ventral spinal CSF leaks. De novo formation of iSCH was established among all 6 patients with iSCH who had undergone prior spinal imaging for symptoms unrelated to iSCH. Among 51 patients with persistent ventral spinal CSF leaks, iSCH developed in 2 patients (probability increased from 0% at 5 years to 9.4% at 10 years). This study shows that iSCH is an acquired condition, and early treatment of ventral CSF leaks offers a unique opportunity to prevent neurologic disability.
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Affiliation(s)
- Wouter I Schievink
- From the Departments of Neurosurgery (W.I.S.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Marcel M Maya
- Imaging (M.M.M.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuño
- Department of Public Health Sciences (M.N.), University of California, Davis, Davis, California
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12
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Risi G, Ducros A, van Dokkum L, Lonjon N, Marchi N, Villain M, Costalat V, Cagnazzo F. Prevalence, clinical presentation, and treatment-management of cerebral venous thrombosis associated with spontaneous intracranial hypotension: A combined case-series and systematic literature review approach. Interv Neuroradiol 2024:15910199241263139. [PMID: 39034592 DOI: 10.1177/15910199241263139] [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: 07/23/2024] Open
Abstract
BACKGROUND Cerebral venous thrombosis (CVT) is a rare complication of spontaneous intracranial hypotension (SIH). Therefore, its correct diagnosis and the corresponding optimal treatment-management identification remains challenging. METHODS Over the last 10 years, 300 patients received a definite SIH diagnosis at our stroke center. Through thorough review of the database, we identified all patients with SIH-related CVT. In addition, we performed a systematic literature review including all publications on SIH-related CVT. RESULTS Five out of our 300 SIH patients showed CVT (F/M:2/3, mean age: 51.8 ± 15.7). Through the literature search, 72 additional cases were identified. Overall, the prevalence was 1.3% and main clinical presentations were orthostatic headache, nausea, and vomiting. The CVT was predominantly located at the superior sagittal sinus. Treatment strategies included anticoagulants (ACs) (43%), epidural blood patch (EBP) (19.4%), and combined AC + EBP (33.3%). In our cohort, all but one patient received combined EBP and AC. The mean clinical and radiological follow-up were 2 years and 1.5 years, respectively. Complete clinical recovery was reported in 96% of the cases, whereas 56% showed complete radiological CVT resolution. Among patients without radiological resolution (26.4%), 57% received AC-only, while 43% received combined AC + EBP. Of our five cases, all but one patient received combined AC + EBP. CONCLUSION The overall prevalence of SIH-related CVT was 1.3%. AC and combined AC + EBP were the most used treatment-management strategies. CVT resolution was more commonly achieved after the combined strategy. Overall, the rate of complete clinical recovery was 96%.
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Affiliation(s)
- Gaetano Risi
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Anne Ducros
- Neurology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Liesjet van Dokkum
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Nicolas Lonjon
- Neurosurgery Department, Montpellier University Hospital, Gui de Chauliac, Montpellier, France
| | - Nicola Marchi
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Max Villain
- Department of Ophthalmology, Gui de Chauliac Hospital, Montpellier, France
| | - Vincent Costalat
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
| | - Federico Cagnazzo
- Neuroradiology Department, Montpellier University Hospital, Gui-de-Chauliac, Montpellier, France
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13
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Schievink WI, Maya MM, Tay ASMS, Taché RB, Prasad RS, Wadhwa V, Nuño M. Lateral Spinal CSF Leaks in Patients with Spontaneous Intracranial Hypotension: Radiologic-Anatomic Study of Different Variants. AJNR Am J Neuroradiol 2024; 45:951-956. [PMID: 38871369 DOI: 10.3174/ajnr.a8261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/15/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND AND PURPOSE Spinal CSF leaks cause spontaneous intracranial hypotension. Several types of leaks have been identified, and one of these types is the lateral dural tear. Performing myelography with the patient in the decubitus position allows precise characterization of these leaks. The purpose of the current study was to describe the different variants of spontaneous lateral CSF leaks. MATERIALS AND METHODS This retrospective cohort study included a consecutive group of patients with spontaneous intracranial hypotension and lateral CSF leaks who underwent digital subtraction myelography in the decubitus position and underwent surgery to repair the CSF leak between July 2018 and June 2023. RESULTS The mean age of the 53 patients (37 women and 16 men) was 35.5 years. Three different variants of lateral CSF leak could be identified. Forty-nine patients (92.5%) had a lateral dural tear associated with the nerve root sleeve. The dural tear was at the axilla of the nerve root sleeve in 36 patients (67.9%) and at the shoulder in 13 patients (24.5%). Four patients (7.5%) had a lateral dural tear at the level of the pedicle that was not associated with the nerve root sleeve. Findings on digital subtraction myelography were concordant with intraoperative findings in all patients. An extradural CSF collection was seen in all patients with a lateral dural tear associated with the nerve root sleeve but in only 2 of the 4 patients with the pedicular variant of a lateral dural tear. CONCLUSIONS We identified 3 variants of spontaneous lateral dural tears. Most lateral dural tears are associated with extradural CSF collections and arise from either the axilla (67.9%) or the shoulder (24.5%) of the nerve root sleeve. Lateral dural tears at the level of the pedicle (7.5%) not associated with the nerve root sleeve are uncommon and may require specialized imaging for their detection.
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Affiliation(s)
- Wouter I Schievink
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Marcel M Maya
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
- Department of Imaging (M.M.M., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Angelique Sao-Mai S Tay
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Rachelle B Taché
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Ravi S Prasad
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
- Department of Imaging (M.M.M., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Vikram Wadhwa
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
- Department of Imaging (M.M.M., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuño
- Department of Public Health Sciences (M.N.), University of California, Davis, California
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14
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Zander C, Wolf K, El Rahal A, Volz F, Beck J, Urbach H, Lützen N. Spontaneous intracranial hypotension - a spinal disease. ROFO-FORTSCHR RONTG 2024. [PMID: 38968964 DOI: 10.1055/a-2318-8994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Spontaneous intracranial hypotension (SIH) remains an underdiagnosed condition despite increasing awareness due to recent scientific advances. Diagnosis can be delayed by the broad clinical presentation and imaging pitfalls. This results in a high degree of physical impairment for patients, including social and psychological sequelae as well as long-term damage in the case of delayed diagnosis and treatment.The study is based on a selective literature search on PubMed including articles from 1990 to 2023 and the authors' clinical experience from working in a CSF center.SIH mostly affects middle-aged women, with the primary symptom being position-dependent orthostatic headache. In addition, there is a broad spectrum of possible symptoms that can overlap with other clinical conditions and therefore complicate the diagnosis. The causative spinal CSF loss can be divided into three main types: ventral (type 1) or lateral (type 2) dural leak and CSF-venous fistula (type 3). The diagnosis can be made using a two-stage workup. As a first step, noninvasive MRI of the head and spine provides indicators of the presence of SIH. The second step using focused myelography can identify the exact location of the cerebrospinal fluid leak and enable targeted therapy (surgical or interventional). Intrathecal pressure measurement or intrathecal injection of gadolinium is no longer necessary for primary diagnosis. Serious complications in the course of the disease can include space-occupying subdural hematomas, superficial siderosis, and symptoms of brain sagging, which can lead to misinterpretations. Treatment consists of closing the dural leak or the cerebrospinal fluid fistula. Despite successful treatment, a relapse can occur, which highlights the importance of follow-up MRI examinations and emphasizes the chronic nature of the disease. This paper provides an overview of the diagnostic workup of patients with suspected SIH and new developments in imaging and therapy. · SIH is an underdiagnosed condition with a wide range of possible symptoms.. · The first diagnostic step using MRI provides indications of the presence of SIH.. · The second diagnostic step using (dynamic) myelography can identify the CSF leak.. · Collaboration with a CSF center is advisable for further diagnosis and treatment.. · Prompt detection and treatment of SIH improves the outcome.. · Zander C, Wolf K, El Rahal A et al. Spontaneous intracranial hypotension - a spinal disease. Fortschr Röntgenstr 2024; DOI 10.1055/a-2318-8994.
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Affiliation(s)
- Charlotte Zander
- Dept. of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
| | - Katharina Wolf
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Amir El Rahal
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Florian Volz
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Dept. of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Horst Urbach
- Dept. of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
| | - Niklas Lützen
- Dept. of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
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15
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Patel NP, Brinjikji W. Cerebrospinal Fluid-Venous Fistulas. Neurosurg Clin N Am 2024; 35:311-318. [PMID: 38782524 DOI: 10.1016/j.nec.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Cerebrospinal fluid-venous fistulas (CSFVFs) were first described in 2014 and have since become an increasingly diagnosed cause of spontaneous intracranial hypotension due to increased clinical recognition and advancements in diagnostic modalities. In this review, the authors discuss CSFVF epidemiology, the variety of clinical presentations, the authors' preferred diagnostic approach, recent advancements in diagnostic methods, treatment options, current challenges, and directions of future research.
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Affiliation(s)
- Nitesh P Patel
- Department of Neurosurgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; Department of Radiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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16
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Carroll I, Han L, Zhang N, Cowan RP, Lanzman B, Hashmi S, Barad MJ, Peretz A, Moskatel L, Ogunlaja O, Hah JM, Hindiyeh N, Barch C, Bozkurt S, Hernandez-Boussard T, Callen AL. Long-Term Epidural Patching Outcomes and Predictors of Benefit in Patients With Suspected CSF Leak Nonconforming to ICHD-3 Criteria. Neurology 2024; 102:e209449. [PMID: 38820488 PMCID: PMC11244740 DOI: 10.1212/wnl.0000000000209449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/12/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Spinal CSF leaks lead to spontaneous intracranial hypotension (SIH). While International Classification of Headache Disorders, Third Edition (ICHD-3) criteria necessitate imaging confirmation or low opening pressure (OP) for SIH diagnosis, their sensitivity may be limited. We offered epidural blood patches (EBPs) to patients with symptoms suggestive of SIH, with and without a documented low OP or confirmed leak on imaging. This study evaluates the efficacy of this strategy. METHODS We conducted a prospective cohort study with a nested case-control design including all patients who presented to a tertiary headache clinic with clinical symptoms of SIH who completed study measures both before and after receiving an EBP between August 2016 and November 2018. RESULTS The mean duration of symptoms was 8.7 ± 8.1 years. Of 85 patients assessed, 69 did not meet ICHD-3 criteria for SIH. At an average of 521 days after the initial EBP, this ICHD-3-negative subgroup experienced significant improvements in Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical Health score of +3.3 (95% CI 1.5-5.1), PROMIS Global Mental Health score of +1.8 (95% CI 0.0-3.5), Headache Impact Test (HIT)-6 head pain score of -3.8 (95% CI -5.7 to -1.8), Neck Disability Index of -4.8 (95% CI -9.0 to -0.6) and PROMIS Fatigue of -2.3 (95% CI -4.1 to -0.6). Fifty-four percent of ICHD-3-negative patients achieved clinically meaningful improvements in PROMIS Global Physical Health and 45% in HIT-6 scores. Pain relief following lying flat prior to treatment was strongly associated with sustained clinically meaningful improvement in global physical health at an average of 521 days (odds ratio 1.39, 95% CI 1.1-1.79; p < 0.003). ICHD-3-positive patients showed high rates of response and previously unreported, treatable levels of fatigue and cognitive deficits. DISCUSSION Patients who did not conform to the ICHD-3 criteria for SIH showed moderate rates of sustained, clinically meaningful improvements in global physical health, global mental health, neck pain, fatigue, and head pain after EBP therapy. Pre-treatment improvement in head pain when flat was associated with later, sustained improvement after EBP therapy among patients who did not meet the ICHD-3 criteria. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that epidural blood patch is an effective treatment of suspected CSF leak not conforming to ICHD-3 criteria for SIH.
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Affiliation(s)
- Ian Carroll
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Lichy Han
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Niushen Zhang
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Robert P Cowan
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Bryan Lanzman
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Syed Hashmi
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Meredith J Barad
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Addie Peretz
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Leon Moskatel
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Oyindamola Ogunlaja
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Jennifer M Hah
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Nada Hindiyeh
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Carol Barch
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Selene Bozkurt
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Tina Hernandez-Boussard
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Andrew L Callen
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
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17
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Friedlander RM. Congenital and Acquired Chiari Syndrome. N Engl J Med 2024; 390:2191-2198. [PMID: 38899696 DOI: 10.1056/nejmra2308055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Affiliation(s)
- Robert M Friedlander
- From the Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh
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18
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Mark IT, Karki P, Cutsforth-Gregory J, Brinjikji W, Madhavan AA, Messina SA, Cogswell PM, Chen JJ, Ehman RL, Huston J, Murphy MC. Evaluation of MR Elastography as a Noninvasive Diagnostic Test for Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2024; 45:662-667. [PMID: 38485194 PMCID: PMC11288542 DOI: 10.3174/ajnr.a8162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/03/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension is a condition resulting from a leak of CSF from the spinal canal arising independent of a medical procedure. Spontaneous intracranial hypotension can present with normal brain MR imaging findings and nonspecific symptoms, leading to the underdiagnosis in some patients and unnecessary invasive myelography in others who are found not to have the condition. Given the likelihood that spontaneous intracranial hypotension alters intracranial biomechanics, the goal of this study was to evaluate MR elastography as a potential noninvasive test to diagnose the condition. MATERIALS AND METHODS We performed MR elastography in 15 patients with confirmed spontaneous intracranial hypotension from September 2022 to April 2023. Age, sex, symptom duration, and brain MR imaging Bern score were collected. MR elastography data were used to compute stiffness and damping ratio maps, and voxelwise modeling was performed to detect clusters of significant differences in mechanical properties between patients with spontaneous intracranial hypotension and healthy control participants. To evaluate diagnostic accuracy, we summarized each examination by 2 spatial pattern scores (one each for stiffness and damping ratio) and evaluated group-wise discrimination by receiver operating characteristic curve analysis. RESULTS Patients with spontaneous intracranial hypotension exhibited significant differences in both stiffness and damping ratio (false discovery rate-corrected, Q < 0.05). Pattern analysis discriminated patients with spontaneous intracranial hypotension from healthy controls with an area under the curve of 0.97 overall, and the area under the curve was 0.97 in those without MR imaging findings of spontaneous intracranial hypotension. CONCLUSIONS Results from this pilot study demonstrate MR elastography as a potential imaging biomarker and a noninvasive method for diagnosing spontaneous intracranial hypotension, including patients with normal brain MR imaging findings.
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Affiliation(s)
- Ian T Mark
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Pragalv Karki
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | | | - Waleed Brinjikji
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Steven A Messina
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Petrice M Cogswell
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - John J Chen
- Department of Neurology (J.C.-G., J.J.C.), Mayo Clinic, Rochester, Minnesota
- Department of Ophthalmology (J.J.C.), Mayo Clinic, Rochester, Minnesota
| | - Richard L Ehman
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - John Huston
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
| | - Matthew C Murphy
- From the Department of Radiology (I.T.M., P.K., W.B., A.A.M., S.A.M., P.M.C., R.L.E., J.H., M.C.M.), Mayo Clinic, Rochester, Minnesota
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19
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Schievink WI, Maya MM, Tay ASMS, Nisson PL, Acharya J, Taché RB, Nuño M. Optic Nerve Sheath MR Imaging Measurements in Patients with Orthostatic Headaches and Normal Findings on Conventional Imaging Predict the Presence of an Underlying CSF-Venous Fistula. AJNR Am J Neuroradiol 2024; 45:655-661. [PMID: 38485201 PMCID: PMC11288531 DOI: 10.3174/ajnr.a8165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/04/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND AND PURPOSE Spontaneous spinal CSF leaks typically cause orthostatic headache, but their detection may require specialized and invasive spinal imaging. We undertook a study to determine the value of simple optic nerve sheath MR imaging measurements in predicting the likelihood of finding a CSF-venous fistula, a type of leak that cannot be detected with routine spine MR imaging or CT myelography, among patients with orthostatic headache and normal conventional brain and spine imaging findings. MATERIALS AND METHODS This cohort study included a consecutive group of patients with orthostatic headache and normal conventional brain and spine imaging findings who underwent digital subtraction myelography under general anesthesia to look for spinal CSF-venous fistulas. RESULTS The study group consisted of 93 patients (71 women and 22 men; mean age, 47.5 years; range, 17-84 years). Digital subtraction myelography demonstrated a CSF-venous fistula in 15 patients. The mean age of these 8 women and 7 men was 56 years (range, 23-83 years). The mean optic nerve sheath diameter was 4.0 mm, and the mean perioptic subarachnoid space was 0.5 mm in patients with a CSF-venous fistula compared with 4.9 and 1.2 mm, respectively, in patients without a fistula (P < .001). Optimal cutoff values were found at 4.4 mm for optic nerve sheath diameter and 1.0 mm for the perioptic subarachnoid space. Fistulas were detected in about 50% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements below these cutoff values compared with <2% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements above these cutoff values. Following surgical ligation of the fistula, optic nerve sheath diameter increased from 4.0 to 5.3 mm and the perioptic subarachnoid space increased from 0.5 to 1.2 mm (P < .001). CONCLUSIONS Concerns about a spinal CSF leak should not be dismissed in patients with orthostatic headache when conventional imaging findings are normal, and simple optic nerve sheath MR imaging measurements can help decide if more imaging needs to be performed in this patient population.
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Affiliation(s)
- Wouter I Schievink
- From the Departments of Neurosurgery (W.I.S., A.S.-M.S.T., P.L.N., R.B.T.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Marcel M Maya
- Departments of Imaging (M.M.M., J.A.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Angelique Sao-Mai S Tay
- From the Departments of Neurosurgery (W.I.S., A.S.-M.S.T., P.L.N., R.B.T.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Peyton L Nisson
- From the Departments of Neurosurgery (W.I.S., A.S.-M.S.T., P.L.N., R.B.T.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Jay Acharya
- Departments of Imaging (M.M.M., J.A.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Rachelle B Taché
- From the Departments of Neurosurgery (W.I.S., A.S.-M.S.T., P.L.N., R.B.T.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuño
- Department of Public Health Sciences (M.N.), University of California, Davis, Davis, California
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20
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Wu JW, Wang SJ. Spontaneous Intracranial Hypotension: Clinical Presentation, Diagnosis, and Treatment Strategies. Neurol Clin 2024; 42:473-486. [PMID: 38575260 DOI: 10.1016/j.ncl.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks. New evidence indicates that a lumbar puncture may not be essential for diagnosing every patient with SIH. Spinal neuroimaging protocols used for diagnosing and localizing spinal cerebrospinal fluid leaks include brain/spinal MRI, computed tomography myelography, digital subtraction myelography, and radionuclide cisternography. Complications of SIH include subdural hematoma, cerebral venous thrombosis, and superficial siderosis. Treatment options encompass conservative management, epidural blood patches, and surgical interventions. The early application of epidural blood patches in all patients with SIH is suggested.
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Affiliation(s)
- Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; Center for Quality Management, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan.
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21
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Sun Y, Pahwa S, Vasireddy RP, Barty A, Raslau FD. Pearls & Oy-sters: Bibrachial Amyotrophy From a Dural Tear. Neurology 2024; 102:e209256. [PMID: 38484224 DOI: 10.1212/wnl.0000000000209256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/10/2024] [Indexed: 03/19/2024] Open
Abstract
Bibrachial amyotrophy signifies a clinical phenotype characterized by weakness in both upper extremities with preserved strength in the face, neck, and lower extremities. The underlying causes of bibrachial amyotrophy are broad. We report a patient exhibiting bibrachial amyotrophy who initially received a diagnosis of amyotrophic lateral sclerosis (ALS); however, his clinical course and NCS/EMG were atypical for ALS. Further evaluation demonstrated dural tears with CSF leak, resulting in a compressive extradural fluid collection, ventral myelopathy, and intracranial hypotension. Dural tear and ALS have overlapping features, including the manifestation of the bibrachial amyotrophy phenotype and the presence of T2 hyperintensities in the anterior horn cells, recognized by an "owl's eye" appearance on spine MRI. Clinical and radiologic vigilance is required to identify rare cases of dural tear causing ventral myelopathy that manifest as bibrachial amyotrophy.
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Affiliation(s)
- Yuyao Sun
- From the Departments of Neurology (Y.S., R.P.V., F.D.R.), Neurosurgery (S.P., F.D.R.), and Radiology (S.P., A.B., F.D.R.), University of Kentucky, Lexington
| | - Shivani Pahwa
- From the Departments of Neurology (Y.S., R.P.V., F.D.R.), Neurosurgery (S.P., F.D.R.), and Radiology (S.P., A.B., F.D.R.), University of Kentucky, Lexington
| | - Rani Priyanka Vasireddy
- From the Departments of Neurology (Y.S., R.P.V., F.D.R.), Neurosurgery (S.P., F.D.R.), and Radiology (S.P., A.B., F.D.R.), University of Kentucky, Lexington
| | - Andrew Barty
- From the Departments of Neurology (Y.S., R.P.V., F.D.R.), Neurosurgery (S.P., F.D.R.), and Radiology (S.P., A.B., F.D.R.), University of Kentucky, Lexington
| | - Flavius D Raslau
- From the Departments of Neurology (Y.S., R.P.V., F.D.R.), Neurosurgery (S.P., F.D.R.), and Radiology (S.P., A.B., F.D.R.), University of Kentucky, Lexington
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22
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Volz F, Wolf K, Fung C, Carroll I, Lahmann C, Lützen N, Urbach H, Klingler JH, Beck J, El Rahal A. Impact of Spinal CSF Leaks on Quality of Life and Mental Health and Long-Term Reversal by Surgical Closure. Neurol Clin Pract 2024; 14:e200272. [PMID: 38585435 PMCID: PMC10996905 DOI: 10.1212/cpj.0000000000200272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/09/2024] [Indexed: 04/09/2024]
Abstract
Background and Objectives Spontaneous intracranial hypotension (SIH) caused by a spinal CSF leak is a multisymptom syndrome, which can dramatically affect physical and mental health. However, systematic data on health-related quality of life (HRQoL) and mental health are scarce. We hypothesized that surgical treatment leads to significant and sustained improvements in HRQoL and mental health in patients with SIH. Methods In this single-center cohort study, we prospectively collected HRQoL and mental health data in patients undergoing surgical closure of a spinal CSF leak from September 2020 to November 2022. EuroQoL (EQ-5D-5L), including the health state index (EQ-Index) and the visual analog scale (EQ-VAS), measured HRQoL. The 21-item version of the Depression Anxiety Stress Scales (DASS-21) measured symptoms of mental health. Follow-ups were performed 3 and 6 months postoperatively. Primary outcome was the change in EQ-Index, EQ-VAS, and DASS-21 subscales. Secondary outcome was the impact of baseline depression symptoms on HRQoL outcomes following surgery. Results Seventy-four patients were included. EQ-VAS improved from 40 (interquartile range [IQR] 30-60) preoperatively to 70 (IQR 55-85) at 3 months and to 72 (IQR 60-88) at 6 months postoperatively (p < 0.001, respectively). EQ-Index increased from 0.683 (IQR 0.374-0.799) to 0.877 (0.740-0.943) at 3 months and to 0.907 (0.780-0.956) at 6 months postoperatively (p < 0.001, respectively). Depression, anxiety, and stress significantly improved after surgery. Preoperative depressive symptoms did not affect the HRQoL outcome. Discussion The severe impact of a spinal CSF leak on HRQoL and mental health significantly improved after closure of the leak. Higher levels of depressive symptoms do not predict worse outcomes and should not discourage invasive treatment. Further systematic evaluation of outcomes, with special regard to quality of life, is needed, as it allows a comparison of symptom burden between SIH and more familiar diseases as well as a comparison of different treatment modalities in future studies.
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Affiliation(s)
- Florian Volz
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Katharina Wolf
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Ian Carroll
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Claas Lahmann
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Niklas Lützen
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Horst Urbach
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Jan-Helge Klingler
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
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23
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Friedman DI. Approach to the Patient With Headache. Continuum (Minneap Minn) 2024; 30:296-324. [PMID: 38568485 DOI: 10.1212/con.0000000000001413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The evaluation of patients with headache relies heavily on the history. This article reviews key questions for diagnosing primary and secondary headache disorders with a rationale for each and phrasing to optimize the information obtained and the patient's experience. LATEST DEVELOPMENTS The availability of online resources for clinicians and patients continues to increase, including sites that use artificial intelligence to generate a diagnosis and report based on patient responses online. Patient-friendly headache apps include calendars that help track treatment response, identify triggers, and provide educational information. ESSENTIAL POINTS A structured approach to taking the history, incorporating online resources and other technologies when needed, facilitates making an accurate diagnosis and often eliminates the need for unnecessary testing. A detailed yet empathetic approach incorporating interpersonal skills enhances relationship building and trust, both of which are integral to successful treatment.
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24
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Cheema S, Mehta D, Qureshi A, Sayal P, Kamourieh S, Davagnanam I, Matharu M. Spontaneous intracranial hypotension. Pract Neurol 2024; 24:98-105. [PMID: 38135500 PMCID: PMC10958270 DOI: 10.1136/pn-2023-003986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is a highly disabling but treatable secondary cause of headache. Recent progress in neuroradiological techniques has catalysed understanding of its pathophysiological basis and clinical diagnosis, and facilitated the development of more effective investigation and treatment methods. A UK-based specialist interest group recently produced the first multidisciplinary consensus guideline for the diagnosis and treatment of SIH. Here, we summarise a practical approach to its clinical and radiological diagnosis, symptomatic and non-targeted interventional treatment, radiological identification of leak site and targeted treatment of the leak once it has been localised.
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Affiliation(s)
- Sanjay Cheema
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Dwij Mehta
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Ayman Qureshi
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Parag Sayal
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Salwa Kamourieh
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Indran Davagnanam
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Manjit Matharu
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
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25
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Chen YC, Yang FC, Huang GS, Chang WC, Hsu YC. Value of CT in targeted CT-guided epidural blood patching: Predictors for successful epidural punctures. J Neuroradiol 2024; 51:204-209. [PMID: 37758171 DOI: 10.1016/j.neurad.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/24/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND PURPOSE Differentiating epidural from intrathecal punctures before computed tomography (CT)-guided epidural blood patching (EBP) is subjective, relying on operator experience. This study aimed to investigate CT findings for epidural and intrathecal punctures and identify reliable predictors for successful epidural punctures before targeted CT-guided EBP. MATERIALS AND METHODS We included 65 patients with low-cerebrospinal fluid (CSF)-pressure headache receiving targeted CT-guided EBP between January 2021 and October 2022 in this retrospective study. We analyzed clinical data, technical information, and CT features before EBP. Fisher's exact test was used for discrete variables, while Mann-Whitney U test was used for continuous variables. Positive (PLR) and negative likelihood ratios (NLR) were calculated to identify predictors for confirming epidural punctures. RESULTS We confirmed 43 patients as epidural punctures and 22 patients as intrathecal punctures. Before contrast injection, epidural fat at the needle tip in the epidural group was higher than the intrathecal group (37.2 % [16/43] vs. 4.5 % [1/22], p = 0.006). After contrast injection, the "contrast-needle tip connection" sign was mostly observed in the epidural group than the intrathecal group (95.3 % [41/43] vs. 9.1 % [2/22], p < 0.001). Additionally, the epidural group had significantly higher boomerang-shaped contrast morphology than the intrathecal group (65.1 % [28/43] vs. 9.1 % [2/22], p < 0.001). The "contrast-needle tip connection" sign had the highest PLR (10.49) and lowest NLR (0.05). CONCLUSION Identifying epidural fat at the needle tip, "contrast-needle tip connection" sign, and boomerang-shaped contrast morphology on CT scans are useful for confirming proper placement of the needle tip within the epidural space.
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Affiliation(s)
- Ya-Che Chen
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan; Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Yi-Chih Hsu
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan.
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Galvan J, Maya M, Prasad RS, Wadhwa VS, Schievink W. Spinal Cerebrospinal Fluid Leak Localization with Digital Subtraction Myelography: Tips, Tricks, and Pitfalls. Radiol Clin North Am 2024; 62:321-332. [PMID: 38272624 DOI: 10.1016/j.rcl.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Cerebrospinal fluid (CSF) leak can cause spontaneous intracranial hypotension (SIH) which can lead to neurologic symptoms, such as orthostatic headache. Over time, imaging techniques for detecting and localizing CSF leaks have improved. These techniques include computed tomography (CT) myelography, dynamic CT myelography, cone-beam CT, MRI, MR myelography, and digital subtraction myelography (DSM). DSM provides the highest sensitivity for identifying leak sites and has comparable radiation exposure to CT myelography. The introduction of the lateral decubitus DSM has proven invaluable in localizing leaks when other imaging tests have been inconclusive.
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Affiliation(s)
- Javier Galvan
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Marcel Maya
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048.
| | - Ravi S Prasad
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Vikram S Wadhwa
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Wouter Schievink
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048; Department of Neurosurgery, Cedars-Sinai Medical Center
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27
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García-Ull J, González-García N, Torres-Ferrús M, García-Azorín D, Molina-Martínez IFJ, Beltrán-Blasco I, Santos-Lasaosa S, Latorre G, Gago-Veiga AB, Láinez JM, Porta-Etessam J, Nieves-Castellanos C, Mínguez-Olaondo A, López-Bravo A, Quintas S, Morollón N, Díaz-Insa S, Belvís R, Irimia P. Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group. Neurologia 2024:S2173-5808(24)00048-8. [PMID: 38431253 DOI: 10.1016/j.nrleng.2024.02.009] [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: 03/05/2024] Open
Abstract
Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.
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Affiliation(s)
- J García-Ull
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain.
| | - N González-García
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain
| | - M Torres-Ferrús
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - D García-Azorín
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Spain
| | - I F J Molina-Martínez
- Servicio de Neurología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - I Beltrán-Blasco
- Unidad de Cefaleas, Servicio de Neurología, Hospital General Universitario Dr. Balmis de Alicante, Spain
| | - S Santos-Lasaosa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - G Latorre
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - A B Gago-Veiga
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
| | - J M Láinez
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - J Porta-Etessam
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - C Nieves-Castellanos
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario y Politécnico la Fe, Instituto de Investigación Sanitaria la Fe, Valencia, Spain
| | - A Mínguez-Olaondo
- Servicio de Neurología, Hospital Universitario Donostia, Instituto de Investigación Biodonostia, Athenea Neuroclinicis, Donostia, Facultad de Ciencias de la Salud, Universidad de Deusto, Bilbao, Spain
| | - A López-Bravo
- Servicio de Neurología, Hospital Reina Sofía de Tudela, Navarra, Spain
| | - S Quintas
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
| | - N Morollón
- Unidas de Cefaleas, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - S Díaz-Insa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario y Politécnico la Fe, Instituto de Investigación Sanitaria la Fe, Valencia, Spain
| | - R Belvís
- Unidas de Cefaleas, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - P Irimia
- Unidad de Cefaleas, Servicio de Neurología, Clínica Universitaria de Navarra, Pamplona, Spain
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Coşarcan SK, Erçelen Ö. The cervical blood patch: A therapeutic "miraculous" for cerebrospinal fluid leaks: A case report. Medicine (Baltimore) 2024; 103:e37035. [PMID: 38306558 PMCID: PMC10843348 DOI: 10.1097/md.0000000000037035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/03/2024] [Indexed: 02/04/2024] Open
Abstract
RATIONALE Cerebrospinal fluid (CSF) leaks, arising from abnormal openings in the protective layers surrounding the spinal cord and brain, are a significant medical concern. These leaks, triggered by various factors including trauma, medical interventions, or spontaneous rupture, lead to the draining of CSF-an essential fluid safeguarding the nervous system. A classic symptom of CSF leaks is an incapacitating headache exacerbated by sitting or standing but relieved by lying down. Spontaneous intracranial hypotension (SIH) denotes the clinical condition marked by postural headaches due to spontaneous CSF leakage and hypotension, often misdiagnosed or underdiagnosed. While orthostatic headaches are the hallmark, SIH may manifest with an array of symptoms including nausea, tinnitus, hearing loss, visual disturbances, and dizziness. Treatment options encompass conservative measures, epidural blood patches (EBP), and surgery, with EBP being the primary intervention. PATIENT CONCERN The patient did not express any specific concerns regarding their medical diagnosis. However, they did harbor apprehensions that their condition might necessitate surgical intervention in the future. DIAGNOSIS The patient had been treated with antibiotics with a pre-diagnosis of sinusitis and was admitted to the neurology department of our hospital when his symptoms failed to improve. Cranial magnetic resonance imaging was interpreted as thickening of the dural surfaces and increased contrast uptake, thought to be due to intracranial hypotension. Cranial MR angiography was normal. Full-spine magnetic resonance imaging revealed a micro-spur at the C2 to 3 level and the T1 to 2 level in the posterior part of the corpus. INTERVENTIONS The cervical EBP was performed in the prone position under fluoroscopic guidance. There were no complications. OUTCOMES The patient was invited for follow-up 1 week after the procedure, and control examination was normal. LESSONS SIH poses a diagnostic challenge due to its diverse clinical presentation and necessitates precise imaging for effective intervention. Cervical EBP emerges as a promising treatment modality, offering relief and improved quality of life for individuals grappling with this condition. However, clinicians must carefully assess patients and discuss potential risks and benefits before opting for cervical blood patches.
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Affiliation(s)
- Sami Kaan Coşarcan
- VKV American Hospital, Department of Anesthesiology, Istanbul, Turkey
- Koç University, School of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Ömür Erçelen
- Koç University, School of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
- VKV American Hospital, Department of Anesthesiology and Algology Clinic, Istanbul, Turkey
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Carlton Jones L, Hoffmann J, Mohideen S, Stanton B, Bleil C, Britton T, Goadsby PJ, Zebian B. Management of cervical CSF-venous fistula causing acute cognitive impairment and coma. Acta Neurochir (Wien) 2024; 166:37. [PMID: 38277029 DOI: 10.1007/s00701-024-05935-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/03/2023] [Indexed: 01/27/2024]
Abstract
CSF-venous fistulas (CVFs) are increasingly recognised as a cause of spontaneous intracranial hypotension. They may present atypically including with brain sagging pseudo-dementia. Cervical CVFs are rare and their management can be difficult due to associated eloquent nerve roots. We report the case of a 49-year-old woman who presented with cognitive decline progressing to coma. Brain imaging showed features of spontaneous intracranial hypotension and a right C7 CVF was identified at digital subtraction and CT myelography. Initial treatment with CT-guided injection of fibrin sealant produced temporary improvement in symptoms before surgical treatment resulted in total clinical remission and radiological resolution.
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Affiliation(s)
- Lalani Carlton Jones
- Department of Neuroradiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
- Department of Radiology, Guy's and St Thomas' Hospitals NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Rd, London, SE1 7EH, UK.
| | - Jan Hoffmann
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Saamir Mohideen
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Biba Stanton
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Cristina Bleil
- Department of Neurosurgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Tom Britton
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Peter J Goadsby
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Bassel Zebian
- Department of Neurosurgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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Orscelik A, Senol YC, Musmar B, Kobeissi H, Bilgin GB, Zandpazandi S, Bilgin C, Pakkam M, Brinjikji W. Endovascular embolization of cerebrospinal fluid-venous fistula: a comprehensive systematic review on its efficacy and safety for the management of spontaneous intracranial hypotension. Neurosurg Rev 2024; 47:28. [PMID: 38163843 DOI: 10.1007/s10143-023-02264-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/20/2023] [Accepted: 12/24/2023] [Indexed: 01/03/2024]
Abstract
Cerebrospinal fluid (CSF)-venous fistula can cause spontaneous intracranial hypotension (SIH) and poses a significant diagnostic and management challenge. This study aims to provide a comprehensive overview of the clinical and radiological outcomes of endovascular embolization as a novel treatment approach for CSF-venous fistula in patients with SIH. This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. The primary outcome was the efficacy of the embolization procedure in occlusion of the CSF-venous fistula, and secondary outcomes included procedural complications and improvement of clinical symptoms and radiological findings. A total of nine studies consisting of 77 patients met the inclusion criteria. Orthostatic and/or Valsalva headache was the most common symptom. The mean age of the patients was 57 ± 8.9 years, and females accounted for 59.7% (46/77) of the cases. Sixty-five (84.4%) patients reported complete resolution or significant improvement in symptoms. The Bern score, Headache Impact Test-6, and the Patient Global Impression of Change scales demonstrated significant improvements in radiological findings and patients' quality of life. Following the procedure, 22 patients (28.6%) experienced rebound intracranial hypertension and 27 patients (35.1%) had transient local pain at the site of the embolization. Our study showed that endovascular embolization is a safe and effective treatment for CSF-venous fistula in patients with SIH, providing complete resolution or significant improvement of clinical symptoms and radiological findings, and positive impacts on patients' quality of life.
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Affiliation(s)
- Atakan Orscelik
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA.
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Yigit Can Senol
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Basel Musmar
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Gokce Belge Bilgin
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Sara Zandpazandi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Madona Pakkam
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
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Nonaka M, Inomata S. Management of Labor and Anesthesia in a Patient With a History of Spontaneous Intracranial Hypotension: A Case Report With Literature Review. Cureus 2024; 16:e52254. [PMID: 38352098 PMCID: PMC10863527 DOI: 10.7759/cureus.52254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a rare disorder characterized by continuous or intermittent cerebrospinal fluid (CSF) leakage from the CSF cavity, which causes symptoms such as headache or neck pain upon standing. However, no well-established measures concerning the type of delivery and anesthesia for pregnant women with a history of SIH have been reported. A woman had developed SIH 9 years earlier from lifting luggage into an overhead bin with stretching movements, which required continuous saline epidural infusion for recovery. Upon the patient's pregnancy at the age of 35 years, although an elective cesarean section (CS) under general anesthesia was planned to avoid SIH recurrence, the patient had an emergency CS at 36 weeks. Since there is no prescribed method of delivery and anesthetic management for patients with a history of SIH, it is important to plan and adapt a treatment strategy based on the patient's wishes and the institution's protocols. As a sidenote, we reviewed the available literature regarding the type of delivery and anesthesia for pregnant women with a history of SIH.
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Affiliation(s)
- Mayuko Nonaka
- Department of Anesthesiology, University of Tsukuba Hospital, Tsukuba, JPN
| | - Shinichi Inomata
- Department of Anesthesiology, Division of Clinical Medicine, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
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Murphy K, Nasralla M, Pron G, Almohaimede K, Schievink W. Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals. Neuroradiology 2024; 66:1-30. [PMID: 37828278 PMCID: PMC10761484 DOI: 10.1007/s00234-023-03226-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/19/2023] [Indexed: 10/14/2023]
Abstract
Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts.
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Affiliation(s)
- Kieran Murphy
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
| | - Mehran Nasralla
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Gaylene Pron
- Dalla Lana School of Public Health, Institute Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Khaled Almohaimede
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Wouter Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, 6Th Floor, Los Angeles, CA, 90048, USA
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Ge S, Wang L, Cui X, Wang XP. Spontaneous intracranial hypotension combined with venous sinus thrombosis: A case series. Asian J Surg 2024; 47:810-812. [PMID: 37891105 DOI: 10.1016/j.asjsur.2023.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Affiliation(s)
- Shihao Ge
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lele Wang
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaocong Cui
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiao-Peng Wang
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
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Callen AL, Fakhri M, Timpone VM, Thaker AA, Dillon WP, Shah VN. Temporal Characteristics of CSF-Venous Fistulas on Dynamic Decubitus CT Myelography: A Retrospective Multi-Institution Cohort Study. AJNR Am J Neuroradiol 2023; 45:100-104. [PMID: 38123910 PMCID: PMC10756577 DOI: 10.3174/ajnr.a8078] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE CSF-venous fistula can be diagnosed with dynamic decubitus CT myelography. This study aimed to analyze the temporal characteristics of CSF-venous fistula visualization on multiphase decubitus CT myelography. MATERIALS AND METHODS A retrospective, multisite study was conducted on patients diagnosed with CSF-venous fistula at 2 institutions between June 2017 and February 2023. Both institutions perform decubitus CT myelography with imaging immediately following injection and usually with at least 1 delayed scan. The conspicuity of CSF-venous fistula was assessed on each phase of imaging. RESULTS Forty-eight patients with CSF-venous fistula were analyzed. CSF-venous fistulas were better visualized on the early pass in 25/48 cases (52.1%), the delayed pass in 6/48 cases (12.5%) and were seen equally on both passes in 15/48 cases (31.3%). Of 25 cases in which the CSF-venous fistula was better visualized on the early pass, 21/25 (84%) fistulas were still at least partially visible on a delayed pass. Of 6 cases in which the CSF-venous fistula was better visualized on a delayed pass, 4/6 (67%) were partially visible on the earlier pass. Six of 48 (12.5%) CSF-venous fistulas were visible only on a single pass. Of these, 4/6 (66.7%) were seen only on the first pass, and 2/6 (33.3%) were seen only on a delayed pass. One fistula was found with one pass only, and one fistula was discovered upon contralateral decubitus imaging without a dedicated second injection. CONCLUSIONS A dynamic decubitus CT myelography imaging protocol that includes an early and delayed phase, likely increases the sensitivity for CSF-venous fistula detection. Further studies are needed to ascertain the optimal timing and technique for CSF-venous fistula visualization on dynamic decubitus CT myelography and its impact on patient outcomes.
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Affiliation(s)
- Andrew L Callen
- From the Department of Radiology (A.L.C., V.M.T., A.A.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mo Fakhri
- Department of Radiology and Biomedical Imaging (M.F., W.P.D., V.N.S.), Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - Vincent M Timpone
- From the Department of Radiology (A.L.C., V.M.T., A.A.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ashesh A Thaker
- From the Department of Radiology (A.L.C., V.M.T., A.A.T.), Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - William P Dillon
- Department of Radiology and Biomedical Imaging (M.F., W.P.D., V.N.S.), Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - Vinil N Shah
- Department of Radiology and Biomedical Imaging (M.F., W.P.D., V.N.S.), Neuroradiology Section, University of California, San Francisco, San Francisco, California
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Cahal M, Roth J, Ungar OJ, Brinjikji W. Fluctuating hearing loss secondary to spontaneous intracranial hypotension: A case report and review of the literature. Interv Neuroradiol 2023:15910199231221863. [PMID: 38146166 DOI: 10.1177/15910199231221863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE Fluctuating sensorineural hearing loss (SNHL) has multiple etiologies, most commonly Ménière's disease (MD), recurrent sudden SNHL, and autoimmune inner ear disorders. Fluctuating SNHL has rarely been described as a symptom of spontaneous intracranial hypotension (SIH). PATIENT A 39-year-old previously healthy female presented with "Ménière's like" symptoms responsive to steroid treatment, which worsened during the day and improved in the supine position. Conservative treatment for MD consisting of low salt and caffeine diet and betahistine medication yielded no improvement. Secondary revision of brain imaging scans showed signs indicative of SIH, and a spinal cerebrospinal fluid leak was ultimately found and treated by a novel technique of transvenous fistula embolization by means of Onyx® glue, leading to gradual clinical improvement and near-complete resolution of symptoms. CONCLUSION SIH should be considered as part of the differential diagnosis of fluctuating SNHL. Clinical and radiological features should be known and sought. We suspect that early diagnosis and treatment can lead to cure and prevent permanent auditory damage.
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Affiliation(s)
- Michal Cahal
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Liaw V, McCreary M, Friedman DI. Quality of Life in Patients With Confirmed and Suspected Spinal CSF Leaks. Neurology 2023; 101:e2411-e2422. [PMID: 37816637 PMCID: PMC10752647 DOI: 10.1212/wnl.0000000000207763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Spontaneous intracranial hypotension (SIH) is a debilitating condition typically producing orthostatic headache limiting upright time. SIH is often difficult to diagnose and treat, negatively affecting quality of life (QoL) in patients with the disorder. We studied QoL in patients with confirmed and suspected SIH using standardized instruments, including suicidality. METHODS We performed a cross-sectional survey of adult patients with confirmed and clinically suspected SIH evaluated in our Headache and Facial Pain Program from 2016 to 2022. Using an online data collection tool (REDCap V 11.2.2), participants completed validated questionnaires assessing general well-being (SF-36), depression (PHQ-9), generalized anxiety disorder-7 (GAD-7), spiritual well-being during chronic illness therapy (FACIT-Sp-12), and headache impact (HIT-6). Subsequently, we interviewed willing participants to administer the Columbia-Suicide Severity Rating Scale (C-SSRS) assessing suicidal behavior and ideation. RESULTS A total of 234 patients met inclusion criteria and were invited to participate in the study, and 95 patients (59 confirmed and 36 clinically suspected) completed the questionnaires. The average age of the cohort was 51.1 years (SD: 15.5), predominantly female (69.5%), White (91.6%), and married (69.5%). Three-quarters (74.5%) scored within the most severe headache category (HIT-6). SF-36 scores were significantly inferior (p < 0.0001) to the general population and lower than reported values for patients with multiple sclerosis and idiopathic intracranial hypertension. Almost half (49.1%) of respondents scored in the moderate depression range or worse (>10), and 25.4% scored with moderate anxiety or worse (>10). FACIT-Sp-12 scores were significantly worse (p < 0.0001) in symptomatic participants than in the validation cohorts of patients with AIDS and cancer. Of the 67 respondents who completed the C-SSRS, more than half (64.2%) endorsed a wish to be dead, and 22.4% had demonstrated suicidal behavior. Patients with symptom-free SIH (n = 22) scored significantly better than symptomatic patients, comparable with the general population. DISCUSSION Based on our single-center cohort, SIH is associated with severe headache pain and high rates of depression, anxiety, and disability, affecting basic activities of daily living. Individuals with confirmed and suspected spinal CSF leaks scored similarly on these measures including suicidality. Outcomes were comparable with the general population after successful treatment or spontaneous remission. Improved identification and treatment of SIH are imperative to improve patients' QoL.
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Affiliation(s)
- Victor Liaw
- From the Department of Neurology (M.M., D.I.F.), University of Texas Southwestern Medical Center (V.L.), Dallas; and Department of Ophthalmology (D.I.F.), University of Texas Southwestern, Dallas
| | - Morgan McCreary
- From the Department of Neurology (M.M., D.I.F.), University of Texas Southwestern Medical Center (V.L.), Dallas; and Department of Ophthalmology (D.I.F.), University of Texas Southwestern, Dallas
| | - Deborah I Friedman
- From the Department of Neurology (M.M., D.I.F.), University of Texas Southwestern Medical Center (V.L.), Dallas; and Department of Ophthalmology (D.I.F.), University of Texas Southwestern, Dallas.
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Lützen N, Aleman EB, El Rahal A, Volz F, Fung C, Beck J, Urbach H. Sacral Dural Tears as a Cause of Spontaneous Intracranial Hypotension. Clin Neuroradiol 2023; 33:957-964. [PMID: 37261452 PMCID: PMC10654183 DOI: 10.1007/s00062-023-01292-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/09/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Dural tears at the level of the cervical, thoracic, and lumbar spine cause spontaneous intracranial hypotension (SIH) in patients with a spinal longitudinal extradural CSF collection (SLEC); however, sacral dural tears have rarely been reported so far. This study focuses on sacral dural tears as a cause of SIH. METHODS Retrospective data from SIH patients with confirmed sacral dural tears studied between October 2020 and November 2022 were analyzed with respect to demographic, clinical and imaging features. Digital subtraction myelography (DSM) and lumbar epidural blood patch (EBP) were modified by placing the patient in reversed Trendelenburg position. RESULTS Of the SIH patients, 9 (all women; mean age, 38.5 years; mean body mass index, BMI, 22.9) out of 149 had a sacral dural leak (6%) that occurred spontaneously in 7/9, while 2/9 were likely associated with minor trauma. None had a sacral fracture. The mean SIH score was 6.8. All patients showed SLEC on heavily T2-weighted MR myelography (T2-MRM), 4/9 exclusively sacral and 5/9 with partial or complete involvement of the remaining spine. 4/9 had none, but 5/9 had meningeal sacral cysts, 2/5 had large cysts/ectasia. Confirmation of the sacral origin of the leak was provided in 4/9 by T2-MRM, in 2/9 by DSM and 3/9 by CT myelography (CTM) whereas 0/9 revealed the exact site of leak within the sacrum. CONCLUSION Sacral dural tears should be considered as a possible cause for SIH. It is concluded to implement T2-MRM covering the entire sacrum in the standard MRI protocol and propose EBP in the reverse Trendelenburg position as a therapeutic approach.
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Affiliation(s)
- Niklas Lützen
- Dept. of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Enrique Barvulsky Aleman
- Dept. of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Amir El Rahal
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Florian Volz
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Christian Fung
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Jürgen Beck
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Horst Urbach
- Dept. of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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Rohatgi VK, Robbins MS, Roytman M, Chazen JL. Spontaneous Intracranial Hypotension in Pregnancy. Curr Pain Headache Rep 2023; 27:685-693. [PMID: 37688759 DOI: 10.1007/s11916-023-01163-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE OF REVIEW Spontaneous intracranial hypotension (SIH) is a debilitating disease typically featuring orthostatic headache and caused by a spinal CSF leak. This review will describe the characteristics of SIH in pregnant patients and the associated unique management and treatment considerations. RECENT FINDINGS Herein, a novel case is reported of a 41-year-old woman who presented with SIH pre-conception but saw marked improvement of symptoms after 5 weeks antepartum and symptom recurrence 2 months post-partum. A literature review of SIH in pregnancy revealed 14 reported patients across 10 studies since 2000. All the reported cases resulted in delivery of healthy infants and symptomatic improvement with conservative management or a variety of treatment modalities including non-targeted epidural blood patch (EBP). Clinical and imaging features of SIH in pregnancy are reviewed. We hypothesize an antenatal protective mechanism against SIH symptoms through cephalad redistribution of CSF volume from the spinal to intracranial compartments related to uterine growth and decreased CSF volume within the lumbar cistern. Treatment recommendations are discussed including duration of bed rest and decision for non-targeted multi-site EBPs. When required, non-invasive diagnostic spine MRI using fat-suppressed axial T2-weighted imaging may be helpful.
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Affiliation(s)
- Varun K Rohatgi
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | | | - Michelle Roytman
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - J Levi Chazen
- Department of Radiology, Hospital for Special Surgery, 535 E 70th St., New York, NY, 10021, USA.
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Hong P, Kapadia A, Lai C, Kingston W, Meng H. Timeliness to definitive treatment to avoid severe neurologic complications associated with spontaneous intracranial hypotension. Can J Anaesth 2023; 70:1854-1856. [PMID: 37594663 DOI: 10.1007/s12630-023-02554-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 08/19/2023] Open
Affiliation(s)
- Patrick Hong
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Anish Kapadia
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Carolyn Lai
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - William Kingston
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Howard Meng
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Cheema S, Anderson J, Angus-Leppan H, Armstrong P, Butteriss D, Carlton Jones L, Choi D, Chotai A, D'Antona L, Davagnanam I, Davies B, Dorman PJ, Duncan C, Ellis S, Iodice V, Joy C, Lagrata S, Mead S, Morland D, Nissen J, Pople J, Redfern N, Sayal PP, Scoffings D, Secker R, Toma AK, Trevarthen T, Walkden J, Beck J, Kranz PG, Schievink W, Wang SJ, Matharu MS. Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry 2023; 94:835-843. [PMID: 37147116 PMCID: PMC10511987 DOI: 10.1136/jnnp-2023-331166] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/21/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND We aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG). METHODS A 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH. RESULTS SIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided. CONCLUSIONS This multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.
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Affiliation(s)
- Sanjay Cheema
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jane Anderson
- Neurology Department, Addenbrooke's Hospital, Cambridge, UK
| | | | - Paul Armstrong
- Neuroradiology Department, Institute of Neurological Sciences, Glasgow, UK
| | - David Butteriss
- Department of Neuroradiology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Lalani Carlton Jones
- Neuroradiology Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
- Neuroradiology Department, King's College Hospital NHS Foundation Trust, London, UK
| | - David Choi
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Amar Chotai
- Department of Neuroradiology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Linda D'Antona
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Indran Davagnanam
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Brendan Davies
- Neurology Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Paul J Dorman
- Department of Neurology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Simon Ellis
- Neurology Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Valeria Iodice
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Clare Joy
- CSF Leak Association, Strathpeffer, UK
| | - Susie Lagrata
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Danny Morland
- Department of Anaesthesia, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Justin Nissen
- Neurosurgery Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Nancy Redfern
- Department of Anaesthesia, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Parag P Sayal
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | | | | | - Ahmed K Toma
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | | | | | - Jürgen Beck
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Peter George Kranz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Wouter Schievink
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shuu-Jiun Wang
- Neurology Department, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Manjit Singh Matharu
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Headache and Facial Pain Group, National Hospital for Neurology and Neurosurgery, London, UK
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Houk JL, Morrison S, Peskoe S, Amrhein TJ, Kranz PG. Validity of the Bern Score as a Surrogate Marker of Clinical Severity in Patients with Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2023; 44:1096-1100. [PMID: 37562827 PMCID: PMC10494944 DOI: 10.3174/ajnr.a7962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND PURPOSE The Bern score is a quantitative scale characterizing brain MR imaging changes in spontaneous intracranial hypotension. Higher scores are associated with more abnormalities on brain MR imaging, raising the question of whether the score can serve as a measure of disease severity. However, the relationship between clinical symptom severity and the Bern score has not been evaluated. Our purpose was to assess correlations between Bern scores and clinical headache severity in spontaneous intracranial hypotension. MATERIALS AND METHODS This study was a single-center, retrospective cohort of patients satisfying the International Classification of Headache Disorders-3 criteria for spontaneous intracranial hypotension. Fifty-seven patients who completed a pretreatment headache severity questionnaire (Headache Impact Test-6) and had pretreatment brain MR imaging evidence of spontaneous intracranial hypotension were included. Pearson correlation coefficients (ρ) for the Headache Impact Test-6 and Bern scores were calculated. Receiver operating characteristic curves were used to assess the ability of Bern scores to discriminate among categories of headache severity. RESULTS We found low correlations between clinical headache severity and Bern scores (ρ = 0.139; 95% CI, -0.127-0.385). Subgroup analyses examining the timing of brain MR imaging, symptom duration, and prior epidural blood patch showed negligible-to-weak correlations in all subgroups. Receiver operating characteristic analysis found that the Bern score poorly discriminated subjects with greater headache severity from those with lower severity. CONCLUSIONS Pretreatment Bern scores show a low correlation with headache severity in patients with spontaneous intracranial hypotension. This finding suggests that brain imaging findings as reflected by Bern scores may not reliably reflect clinical severity and should not replace clinical metrics for outcome assessment.
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Affiliation(s)
- J L Houk
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - S Morrison
- Department of Biostatistics and Bioinformatics (S.M., S.P.), Duke University School of Medicine, Durham, North Carolina
| | - S Peskoe
- Department of Biostatistics and Bioinformatics (S.M., S.P.), Duke University School of Medicine, Durham, North Carolina
| | - T J Amrhein
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - P G Kranz
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
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Volz F, Fung C, Wolf K, Lützen N, Urbach H, Kraus LM, Omer M, Beck J, El Rahal A. Recovery and long-term outcome after neurosurgical closure of spinal CSF leaks in patients with spontaneous intracranial hypotension. Cephalalgia 2023; 43:3331024231196808. [PMID: 37652456 DOI: 10.1177/03331024231195830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid leak causes orthostatic headaches and impacts quality of life. Successful closure rates are often reported, whereas data on long-term outcome are still scarce. METHODS Between April 2020 and December 2022 surgically treated patients completed the Headache Impact Test-6 prior to surgery and at 14 days, three months, six months, and 12 months postoperatively. In addition to the Headache Impact Test-6 score, we extracted data related to orthostatic symptoms. RESULTS Eighty patients were included. Median Headache Impact Test-6 score preoperatively was 65 (IQR 61-69), indicating severe and disabling impact of headaches. At three months headache impact significantly improved to 49 (IQR 44-58) (p < 0.001) and remained stable up to 12 months (48, IQR 40-56), indicating little to no impact of headaches on quality of life. The need to lie down "always" or "very often" was reduced from 79% to 23% three months postoperatively (p < 0.001). CONCLUSIONS Surgical closure of spinal CSF leaks significantly improves the impact of headaches in the long term. At least three months should be expected for recovery. Despite permanent closure of the CSF-leak, a quarter of patients still have relevant long-term impairment, indicating the need for further research on its cause and possible treatment.
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Affiliation(s)
- Florian Volz
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Luisa Mona Kraus
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Mazin Omer
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Kurokawa R, Kurokawa M, Isshiki S, Harada T, Nakaya M, Baba A, Naganawa S, Kim J, Bapuraj J, Srinivasan A, Abe O, Moritani T. Dural and Leptomeningeal Diseases: Anatomy, Causes, and Neuroimaging Findings. Radiographics 2023; 43:e230039. [PMID: 37535461 DOI: 10.1148/rg.230039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Meningeal lesions can be caused by various conditions and pose diagnostic challenges. The authors review the anatomy of the meninges in the brain and spinal cord to provide a better understanding of the localization and extension of these diseases and summarize the clinical and imaging features of various conditions that cause dural and/or leptomeningeal enhancing lesions. These conditions include infectious meningitis (bacterial, tuberculous, viral, and fungal), autoimmune diseases (vasculitis, connective tissue diseases, autoimmune meningoencephalitis, Vogt-Koyanagi-Harada disease, neuro-Behçet syndrome, Susac syndrome, and sarcoidosis), primary and secondary tumors (meningioma, diffuse leptomeningeal glioneuronal tumor, melanocytic tumors, and lymphoma), tumorlike diseases (histiocytosis and immunoglobulin G4-related diseases), medication-induced diseases (immune-related adverse effects and posterior reversible encephalopathy syndrome), and other conditions (spontaneous intracranial hypotension, amyloidosis, and moyamoya disease). Although meningeal lesions may manifest with nonspecific imaging findings, correct diagnosis is important because the treatment strategy varies among these diseases. ©RSNA, 2023 Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Ryo Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Mariko Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Saiko Isshiki
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Taisuke Harada
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Moto Nakaya
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Akira Baba
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Shotaro Naganawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - John Kim
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Jayapalli Bapuraj
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Ashok Srinivasan
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Osamu Abe
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Toshio Moritani
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
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Zduńska A, Cegielska J, Zduński S, Domitrz I. Caffeine for Headaches: Helpful or Harmful? A Brief Review of the Literature. Nutrients 2023; 15:3170. [PMID: 37513588 PMCID: PMC10385675 DOI: 10.3390/nu15143170] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 07/14/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023] Open
Abstract
Consumption of caffeine in the diet, both daily and occasional, has a significant biological effect on the nervous system. Caffeine, through various and not yet fully investigated mechanisms, affects headaches. This is especially noticeable in migraine. In other headaches such as hypnic headache, post-dural puncture headache and spontaneous intracranial hypotension, caffeine is an important therapeutic agent. In turn, abrupt discontinuation of chronically used caffeine can cause caffeine-withdrawal headache. Caffeine can both relieve and trigger headaches.
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Affiliation(s)
- Anna Zduńska
- Department of Neurology, Faculty of Medicine and Dentistry, Medical University of Warsaw, 01-809 Warsaw, Poland
| | - Joanna Cegielska
- Department of Neurology, Faculty of Medicine and Dentistry, Medical University of Warsaw, 01-809 Warsaw, Poland
| | - Sebastian Zduński
- Medical Rehabilitation Facility, The National Institute of Medicine of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
| | - Izabela Domitrz
- Department of Neurology, Faculty of Medicine and Dentistry, Medical University of Warsaw, 01-809 Warsaw, Poland
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Huang P. Rare cause of cerebral venous sinus thrombosis: Spontaneous intracranial hypotension syndrome: A case report. World J Clin Cases 2023; 11:4677-4683. [PMID: 37469739 PMCID: PMC10353506 DOI: 10.12998/wjcc.v11.i19.4677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/28/2023] [Accepted: 05/08/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension syndrome is a relatively uncommon neurological disorder of unknown etiology with a good prognosis. Cerebral venous sinus thrombosis is a specific type of cerebrovascular disease caused by multiple etiologies of cerebral venous sinus or vein thrombosis that obstructs cerebral venous return and is associated with impaired cerebrospinal fluid absorption; this entity is rarely seen clinically. Spontaneous intracranial hypotension syndrome is one of the causes of cerebral venous sinus thrombosis, and the probability of their combined occurrence is only 1%-2%. As such, it is easily overlooked clinically, thus increasing the difficulty of diagnosis and treatment.
CASE SUMMARY A 29-year-old young woman presented with postural headache. Lumbar puncture suggested a pressure of 50 mmH2O (normal 80 mmH2O-180 mmH2O), and magnetic resonance imaging cerebral venography suggested thrombosis of the supratentorial sinus. These findings were considered indicative of cerebral venous sinus thrombosis due to spontaneous intracranial hypotension syndrome after ruling out immunological causes, tumor, infection, abnormal coagulation mechanism, and hypercoagulable state, etc. She was treated with rehydration and low-molecular heparin anticoagulation for 15 d, and follow-up magnetic resonance imaging cerebral venography suggested resolution of the thrombus. The patient had complete improvement of her headache symptoms.
CONCLUSION Spontaneous intracranial hypotension syndrome is one of the rare causes of cerebral venous sinus thrombosis, which is frequently misdiagnosed or missed and deserves consideration by clinicians during differential diagnosis. Dehydration should be avoided in such patients, and early rehydration and anticoagulation therapy are effective treatment options.
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Affiliation(s)
- Pan Huang
- Department of Neurology, People’s Hospital of Deyang City, Deyang 618000, Sichuan Province, China
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Mariappan R, Kumar S, Raju K, Daniel D, Nair SC, Subramani S. Comparing two techniques of performing an epidural catheter-assisted epidural blood patch using a 20 ml syringe versus a 5 ml syringe and its effect on clotting time, the strength of clot retraction and haemolysis - A prospective in vitro study (EC-EBP study). Indian J Anaesth 2023; 67:544-547. [PMID: 37476432 PMCID: PMC10355359 DOI: 10.4103/ija.ija_849_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/15/2023] [Accepted: 04/08/2023] [Indexed: 07/22/2023] Open
Abstract
Background and Aims Epidural blood patch (EBP) is performed by injecting autologous blood into the epidural space using a Tuohy needle. Certain clinical scenarios mandate an epidural catheter (EC)-assisted EBP. Collecting blood in a 20-ml versus 5-ml syringe appears to influence the quality of the clot. This in vitro study compared the techniques of performing the EC-assisted EBP using 20-ml versus 5-ml syringe on clotting time (CT), clot retraction (CR) and haemolysis. Methods This in vitro study was performed in a haematology laboratory. Five consented adult healthy male volunteers donated blood. In the 5-ml syringe technique, blood was injected through an EC, and as it flowed out of the tip, it was collected at the beginning and the end of 1 min. With the 20-ml technique, blood was collected at the beginning and end of the first, second and third minute. The samples were tested for CT, CR and haemolysis by measuring the plasma-free haemoglobin (PFHb). Results Five injections were made using a 5-ml syringe, and another five with a 20-ml syringe. Injection time was shorter in the 5-ml technique (80.80 ± 5.89 vs. 272 ± 28.4 s, P < 0.0001). With the 20-ml technique, CT progressively increased (>15 min), whereas, with the 5-ml syringe, the CT was normal. Both techniques caused mild, insignificant haemolysis (PFHb >0.005 g/dl), without affecting the quality of CR. Conclusion EC-assisted EBP using a 5-ml syringe technique shortens the injection time and deposits fresh blood quickly without affecting CT and CR.
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Affiliation(s)
- Ramamani Mariappan
- Department of Neuroanaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | - Snehil Kumar
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Krishnaprabhu Raju
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dolly Daniel
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sukesh Chandran Nair
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sathya Subramani
- Department of Physiology, Christian Medical College, Vellore, Tamil Nadu, India
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Bin Wan Hassan WMN, Mistretta F, Molinaro S, Russo R, Bosco G, Gambino A, Bergui M. Overview of Spontaneous Intracranial Hypotension and Differential Diagnosis with Chiari I Malformation. J Clin Med 2023; 12:jcm12093287. [PMID: 37176727 PMCID: PMC10179697 DOI: 10.3390/jcm12093287] [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: 02/15/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.
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Affiliation(s)
| | - Francesco Mistretta
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Giovanni Bosco
- Department of Neuroscience, Stroke Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Andrea Gambino
- Department of Surgical Sciences, Radiology Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
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Pinto MJ, Braz L, Fonseca J, Pereira P, Trigo Barbosa P, Gomes A, Guimarães J. [Guidelines for the Diagnosis and Treatment of Spontaneous Intracranial Hypotension]. ACTA MEDICA PORT 2023; 36:363-367. [PMID: 37130571 DOI: 10.20344/amp.19432] [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: 12/07/2022] [Accepted: 02/23/2023] [Indexed: 05/04/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is a syndrome characterized by disabling orthostatic headache, due to reduced cerebrospinal fluid (CSF) volume probably caused by a CSF fistula. It affects mostly women of working-age, although it is probably underdiagnosed. The aim of this article is to present a practical approach to the diagnosis and treatment of SIH. After a description of its symptoms and signs, we present a step-by-step approach to the confirmation of the diagnosis and treatment, considering different clinical scenarios. This is intended to guide clinical decision making, through a systematized and individualized management, aimed at the best interest of the patient.
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Affiliation(s)
- Maria João Pinto
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Luís Braz
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - José Fonseca
- Serviço de Neurorradiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Paulo Pereira
- Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto; Serviço de Neurocirurgia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Paula Trigo Barbosa
- Unidade de Dor Crónica. Serviço de Anestesiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Armanda Gomes
- Unidade de Dor Crónica. Serviço de Anestesiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Joana Guimarães
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
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Huang W, Hua C, Guo Y, Gao W, Li Y, Zheng Y. Super resolution imaging reconstruction reveals that gold standard methods may not correctly conclude neural/brain functional recovery. Comput Med Imaging Graph 2023; 105:102198. [PMID: 36805708 DOI: 10.1016/j.compmedimag.2023.102198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/17/2022] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
The status of cerebral perfusion and its restoration level play a vital role in the prognosis and clinical decision making of many neurosurgical diseases. As such, gold standard methods including CT, MR and ICP monitoring, which can indicate and measure cerebral perfusion and restoration, have been widely adopted to evaluate whether or not a patient has recovered from neurofunctional disabilities. This robust combination of methods, however, is confronted with a growing number of contradictions in recent years due to its inability to measure the status of cerebral reperfusion in microvasculature level, even though this has been shown to determine neurofunctional restoration as well or even better. To this date, nevertheless, we have very limited imaging methods that could evaluate human cerebral microperfusion both safely and accurately under most neurosurgical conditions. We herein report a new method of acquiring a patient's cerebral microperfusion status noninvasively which could display the precise distribution of microvasculature in deep cerebral regions with a resolution of ∼30 µm, using everyday bed-side ultrasonography combined with a computerized super-resolution reconstruction algorithm. Using this imaging modality, we found that a patient's cerebral microperfusion might not be improved by some routine administrations even though the gold standard method had yielded the opposite conclusions. Our imaging modality retains the safe, portable feature of ordinary ultrasonography while possesses the extraordinary super-resolution nature, which enables an efficient, precise diagnosis of cerebral perfusion. Most importantly, the super resolution nature of this method may also facilitate early-stage evaluation of a patient's neurofunctional restoration level and avoid overoptimistic conclusions from conventional angiography or ICP monitoring.
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Affiliation(s)
- Weifeng Huang
- Department of Critical Care Medicine, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Hua
- Department of Ultrasound, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Center for Brain Science, Shanghai, China.
| | - Yan Guo
- Department of Neurosurgery, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenwei Gao
- Department of Neurosurgery, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchuan Li
- Department of Critical Care Medicine, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Yuanyi Zheng
- Department of Ultrasound, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Mehta D, Cheema S, Davagnanam I, Matharu M. Diagnosis and treatment evaluation in patients with spontaneous intracranial hypotension. Front Neurol 2023; 14:1145949. [PMID: 36970531 PMCID: PMC10036855 DOI: 10.3389/fneur.2023.1145949] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Spontaneous intracranial hypotension is characterized by an orthostatic headache and audiovestibular symptoms alongside a myriad of other non-specific symptoms. It is caused by an unregulated loss of cerebrospinal fluid at the spinal level. Indirect features of CSF leaks are seen on brain imaging as signs of intracranial hypotension and/or CSF hypovolaemia as well as a low opening pressure on lumbar puncture. Direct evidence of CSF leaks can frequently, but not invariably, be observed on spinal imaging. The condition is frequently misdiagnosed due to its vague symptoms and a lack of awareness of the condition amongst the non-neurological specialities. There is also a distinct lack of consensus on which of the many investigative and treatment options available to use when managing suspected CSF leaks. The aim of this article is to review the current literature on spontaneous intracranial hypotension and its clinical presentation, preferred investigation modalities, and most efficacious treatment options. By doing so, we hope to provide a framework on how to approach a patient with suspected spontaneous intracranial hypotension and help minimize diagnostic and treatment delays in order to improve clinical outcomes.
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Affiliation(s)
- Dwij Mehta
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- *Correspondence: Dwij Mehta
| | - Sanjay Cheema
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Indran Davagnanam
- Lysholm Department of Neuroradiology, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Manjit Matharu
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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