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Karm MH, Choi JH, Kim D, Park JY, Yun HJ, Suh JH. Predictors of the Treatment Response of Spontaneous Intracranial Hypotension to an Epidural Blood Patch. Medicine (Baltimore) 2016; 95:e3578. [PMID: 27149484 PMCID: PMC4863801 DOI: 10.1097/md.0000000000003578] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is characterized by postural headache because of low cerebrospinal fluid (CSF) pressure. Brain magnetic resonance imaging (MRI) and radioisotope (RI) cisternography can be used to identify the site of a CSF leakage. Although autologous epidural blood patch (EBP) is a very effective treatment modality, some patients require a repeat autologous EBP. We investigated whether autologous EBP responses correlate with surrogate markers of quantitative findings.All cases of autologous EBP for SIH from January 2006 to December 2014 were enrolled. The demographic variables, number of EBPs, pain scores, RI cisternography (early visualization of bladder activity), and MRI findings (subdural fluid collections, pachymeningeal enhancement, engorgement of venous structures, pituitary hyperemia, and sagging of the brain) were reviewed.Patients with early bladder activity on RI cisternography had a tendency to need a higher number of autologous EBPs. Only sagging of the brain and no other variables showed a statistically significant negative correlation with the number of autologous EBPs.The response to autologous EBP may be related to the radiologic findings of early bladder activity on RI cisternography and sagging of the brain on MRI.
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Affiliation(s)
- Myong-Hwan Karm
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Retrospective study of epidural blood patch use for spontaneous intracranial hypotension. Reg Anesth Pain Med 2015; 40:58-61. [PMID: 25493688 DOI: 10.1097/aap.0000000000000194] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Spontaneous intracranial hypotension (SIH) is characterized by a severe and disabling headache that is usually orthostatic in nature. Cisternography is a useful diagnostic test for evaluating the presence and location of cerebrospinal fluid (CSF) leakage, and a targeted epidural blood patch (EBP) based on the cisternography findings is a very effective treatment modality for SIH. However, the effects of EBPs are not predictable, making repeat EBPs essential in some cases. The aim of the present study was to find the relationship between the EBP response and cisternographic findings, hypothesizing that the number of required EBPs would increase with an increased number of CSF leakage levels as determined by radionuclide cisternography. METHODS All patients who underwent an EBP and had been discharged with significant improvements in symptoms of SIH during 2006 to 2011 were enrolled. Patients who had no radionuclide cisternographic results were excluded. The demographic variables, number of EBPs, cisternographic findings (location, bilaterality, and number of leakage sites), and preprocedural and postprocedural pain scores were reviewed. RESULTS There was no correlation found between the cisternographic findings and the number of EBPs. Only the preprocedural pain scores showed a statistically significant correlation with the number of EBPs. CONCLUSIONS Our study suggests that the response to the EBP is related to the severity of symptoms but not to the number and locations of cisternographic CSF leakages.
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Lu YY, Wang HY, Lin Y, Lin WY. The Value of Changing Position in the Detection of CSF Leakage in Spontaneous Intracranial Hypotension Using Tc-99m DTPA Scintigraphy: Two Case Reports. IRANIAN JOURNAL OF RADIOLOGY 2013; 9:150-3. [PMID: 23329981 PMCID: PMC3522372 DOI: 10.5812/iranjradiol.7956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 08/01/2012] [Accepted: 08/11/2012] [Indexed: 11/16/2022]
Abstract
Radionuclide Cisternography (RNC) is of potential value in pointing out the sites of cerebrospinal fluid (CSF) leakage in patients with spontaneous intracranial hypotension (SIH). In the current report, we present two patients who underwent RNC for suspected CSF leakage. Both patients underwent magnetic resonance imaging (MRI) and RNC for evaluation. We describe a simple method to increase the detection ability of RNC for CSF leakage in patients with SIH.
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Affiliation(s)
- Yu Yu Lu
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsin Yi Wang
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ying Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wan Yu Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Corresponding author: Wan-Yu Lin, Department of Nuclear Medicine, 160, Sec. 3, Chung-Kang Rd, Taichung, 407, Taiwan. Tel.: +886-423741349, Fax: +886-423741348, E-mail:
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Tc-99m DTPA cisternography shows disappearance of cerebrospinal fluid leakage after standing a short time. Clin Nucl Med 2008; 34:29-30. [PMID: 19092380 DOI: 10.1097/rlu.0b013e31818f446e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yoo HM, Kim SJ, Choi CG, Lee DH, Lee JH, Suh DC, Choi JW, Jeong KS, Chung SJ, Kim JS, Yun SC. Detection of CSF leak in spinal CSF leak syndrome using MR myelography: correlation with radioisotope cisternography. AJNR Am J Neuroradiol 2008; 29:649-54. [PMID: 18202233 DOI: 10.3174/ajnr.a0920] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal CSF leak syndrome is a unique disorder caused by spinal CSF leak. In this study, we attempted to determine whether MR myelography (MRM) can detect the leakage site in the spine. MATERIALS AND METHODS We performed both MRM and radioisotope cisternography (RIC) in 15 patients with spinal CSF leak syndrome. Patients were included in this study if they had at least 2 of the following criteria: 1) orthostatic headache, 2) low CSF opening pressure, and 3) diffuse pachymeningeal enhancement on brain MR imaging. For comparison, we performed MRM in 15 subjects without symptoms of spinal CSF leak syndrome. MRM was performed with the 2D turbo spin-echo technique in the entire spine by using a 1.5T scanner. Two blinded radiologists evaluated the MRM findings in a total of 30 cases, composed of patient and control groups, with regard to the presence of leakage and the level of leakage if present. RIC was performed only in the patient group and was assessed by consensus among 3 physicians experienced in nuclear medicine. The diagnostic performance of MRM and RIC was evaluated on the basis of the clinical diagnosis of spinal CSF leak syndrome. RESULTS The sensitivity, specificity, and accuracy of MR myelography for detecting CSF leak was 86.7%, 86.7%, and 86.7% for reader 1, respectively, and 80.0%, 93.3%, and 86.7% for reader 2, respectively. The sensitivity of RIC was 93.3%. Agreement between the 2 techniques for the detection of CSF leak was substantial in reader 1 and moderate in reader 2 (kappa = 0.634 and 0.444, respectively). CONCLUSION MRM is an effective tool for detecting CSF leak in the spine in patients with spinal CSF leak syndrome.
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Affiliation(s)
- H-M Yoo
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Ishikawa S, Yokoyama M, Mizobuchi S, Hashimoto H, Moriyama E, Morita K. Epidural blood patch therapy for chronic whiplash-associated disorder. Anesth Analg 2007; 105:809-14. [PMID: 17717243 DOI: 10.1213/01.ane.0000271922.04981.33] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite the absence of objective neurological deficits, patients with chronic whiplash-associated disorder (WAD) complain of symptoms such as headache, dizziness, and nausea. These symptoms are also often experienced by patients with cerebrospinal fluid (CSF) leak. It was recently reported that radioisotope (RI) cisternography is useful in the diagnosis of intracranial hypotension due to CSF leak. We investigated the relation between chronic WAD and CSF leak by RI cisternography and evaluated whether epidural blood patch (EBP) administration is effective in the treatment of chronic WAD. METHODS We studied 66 patients with chronic WAD with symptoms lasting longer than 3 mo. All patients underwent RI cisternography to determine the presence of CSF leak. In patients in whom CSF leak was identified, EBP was administered. Symptoms were assessed before, 1 wk after, and 6 mo after EBP. Work status was also assessed and follow-up RI cisternography was performed. RESULTS Of the 66 patients, 37 showed CSF leak, and 36 of these patients received EBP 2.2 +/- 0.7 times. The mean duration of symptoms was 33 mo. One week after EBP, the percentage of patients with symptoms was decreased significantly compared with that before EBP; headache: 100% vs 17%, respectively, memory loss: 94% vs 28%, dizziness: 83% vs 47%, visual impairment: 81% vs 25%, nausea: 78% vs 42% (P < 0.01). These effects were also observed at the 6 month follow-up examination (P < 0.01). Work status was also significantly improved at follow-up. CONCLUSIONS We conclude that CSF leak should be considered in some cases of chronic WAD and that EBP is an effective therapy for chronic WAD.
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Affiliation(s)
- Shinichi Ishikawa
- Department of Anesthesiology, Fukuyama Kohnan Hospital, Kohnan-cho, Fukuyama City, Hiroshima, Japan
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Cumarasingam B, Mansberg R, Mansberg V, Szeto E, Garrick R. Multimodality Imaging of a Spontaneous Cerebrospinal Fluid Leak. Clin Nucl Med 2007; 32:210-2. [PMID: 17314599 DOI: 10.1097/rlu.0b013e31803073e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Brenda Cumarasingam
- Department of Nuclear Medicine, St. Vincent's Hospital, Darlinghurst, Australia
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Sayer FT, Bodelsson M, Larsson EM, Romner B. Spontaneous Intracranial Hypotension Resulting in Coma: Case Report. Neurosurgery 2006; 59:E204; discussion E204. [PMID: 16823289 DOI: 10.1227/01.neu.0000219843.34356.ee] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Spontaneous intracranial hypotension is a potentially severe condition characterized by a distinct clinical picture caused by low cerebrospinal fluid pressure. Although coma has been reported previously as a presentation of this condition, this is the first report in which misdiagnosis of this condition and unwarranted surgery led to coma. CLINICAL PRESENTATION A 62-year-old man presented with a history of headache, and cranial magnetic resonance imaging showed bilateral chronic subdural hematomas. After evacuation of the hematoma, the patient's condition deteriorated into a state of profound depression of consciousness. Repeated cranial computed tomographic scans showed intracranial air, and intracranial pressure monitoring showed negative recording. Spinal magnetic resonance imaging demonstrated epidural cerebrospinal fluid leaks at the middle and lower thoracic levels. INTERVENTION Epidural blood patch resulted in almost immediate improvement in the patient's condition, and he was fully awake 24 hours later. CONCLUSION This case report expands the presently known clinical spectrum of this uncommon and generally benign illness.
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Affiliation(s)
- Faisal T Sayer
- Department of Neurosurgery, Lund University Hospital, Lund, Sweden.
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Kong DS, Park K, Nam DH, Lee JI, Kim JS, Eoh W, Kim JH. Clinical features and long-term results of spontaneous intracranial hypotension. Neurosurgery 2006; 57:91-6; discussion 91-6. [PMID: 15987544 DOI: 10.1227/01.neu.0000163093.38616.35] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2004] [Accepted: 02/10/2005] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Although spontaneous intracranial hypotension (SIH) is an increasingly recognized syndrome, the long-term outcomes have not been established. We conducted a long-term follow-up study to clarify the clinical features and long-term outcomes of patients with this disorder. METHODS We performed a retrospective study in 13 consecutive patients with SIH treated between 1998 and 2003. The diagnosis of intracranial hypotension was made on the basis of clinical symptoms, lumbar puncture, radiological studies (e.g. brain magnetic resonance imaging, spine magnetic resonance imaging, computed tomographic myelography) and radionuclide cisternography. We collected follow-up clinical information of the patients by telephone or by examination at an outpatient clinic. RESULTS All patients were treated by nonsurgical conservative treatments, such as absolute bed rest, intravenous hydration and repetitive epidural blood patch (5 patients). The mean duration of follow up was 51.4 months (range, 15-80 mo). Among 13 patients included in this study, only one patient (7.7%) developed recurrent SIH, and the other patients improved from orthostatic headache. Although 7 of 13 patients had complete resolution of headache at a minimum of 2 years follow-up, 4 patients had mild headache and 2 patients continued to have moderate headache at the final examination. CONCLUSION In this series, the outcome of SIH after conservative treatment was not as satisfactory as that reported in previous studies. We conclude that periodic follow-up examinations must be performed and a more effective treatment modality developed to achieve complete resolution of SIH.
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Affiliation(s)
- Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Takahashi M, Momose T, Kameyama M, Mizuno S, Kumakura Y, Ohtomo K. Detection of cerebrospinal fluid leakage in intracranial hypotension with radionuclide cisternography and blood activity monitoring. Ann Nucl Med 2005; 19:339-43. [PMID: 16097647 DOI: 10.1007/bf02984630] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Radionuclide cisternography is an indispensable examination to detect cerebrospinal fluid (CSF) leakage in patients suspected of having spontaneous intracranial hypotension (SIH). However, it sometimes fails to demonstrate the site of CSF leakage, and in such cases, early bladder visualization is utilized for the diagnosis of SIH as an indirect finding. The aim of this work is to improve the diagnostic ability of radionuclide cisternography and to reevaluate the reliability of early bladder visualization as an indirect finding of CSF leakage. METHODS We obtained serial images during the first hour after injection as well as the following time points in 4 patients with SIH and 5 with normal pressure hydrocephalus (NPH) as a control. We also performed blood sampling over time to measure blood radioactivity concentrations. RESULTS All 4 patients with SIH demonstrated leakage, 2 of 4 within one hour after injection. Bladder visualization was observed falsely in 4 of 5 patients with NPH, considered to be the result of a lumbar puncture complication. In this false bladder visualization, blood radioactivity showed a more rapid raise and fall than in CSF leakage of SIH. CONCLUSIONS The combination of radionuclide cisternography, including early time points and blood sampling, may enable accurate diagnosis of SIH.
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Affiliation(s)
- Miwako Takahashi
- Department of Radiology, The University of Tokyo, Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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Mitjavila M, Balsa MA, Penín J, Pey C. [Radionuclide cisternography in spontaneous intracranial hypotension syndrome]. ACTA ACUST UNITED AC 2005; 23:338-42. [PMID: 15450139 DOI: 10.1016/s0212-6982(04)72313-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Spontaneous intracranial hypotension (SHI) due to cerebrospinal fluid (CSF) leaks is a clinical entity that is being increasingly recognized. Orthostatic headache is the cardinal clinical manifestation of this disorder. PATIENTS AND METHOD Seven patients were studied retrospectively because of postural headache associated with low CSF pressure. In all patients, radionuclide cisternography as well as CT and/or MRI were performed. Radionuclide cisternography was obtained after intrathecal injection of radioisotope into the lumbar subarachnoide space. Images were obtained at 30 minutes, 2 and 4 hours after the injection. Pledgets were inserted into the nose and were considered positive for the presence of CSF when the count index of the pledgets regarding a blood sample was > or = 2:1. Criteria of spontaneous SHI was the early appearance of bladder activity with decrease in the distribution in the cerebral convexity and/or visualization of activity in the paraspinal areas. RESULTS In 5 of the 7 patients scintigraphic abnormalities were found. CONCLUSION Radionuclide cisternography is a reliable diagnostic method to diagnose SHI.
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Affiliation(s)
- M Mitjavila
- Medicina Nuclear, Hospital Universitario de Getafe, Madrid.
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Jeyrani R, Paul A, Doerfler A, Egelhof T. Intracranial hypotension due to leakage of cerebrospinal fluid: could myelography be a therapeutic option? Neuroradiology 2005; 47:43-5. [PMID: 15655661 DOI: 10.1007/s00234-003-1089-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2003] [Accepted: 07/23/2003] [Indexed: 10/25/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an uncommon condition caused by cerebrospinal fluid leakage. We report of a 29-year-old woman with typical symptoms in whom initial cranial MRI and CT were normal . A clinical diagnosis of SIH, but the symptoms did not resolve with conservative therapy or a lumbar epidural blood patch. Repeat MRI revealed (indirect) findings consistent with SIH but failed to directly demonstrate a cerebrospinal fluid fistula. Subsequent CT myelography revealed leakage of contrast medium into the epidural space bilaterally along the nerve roots at C3-7. Following the myelography the patient reported dramatic clinical improvement with complete resolution of symptoms. The adhesive quality of the myelographic contrast medium might have precipitated closure of the meningeal tears. Myelography may be not only of diagnostic value but also therapeutic in SIH.
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Affiliation(s)
- R Jeyrani
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany.
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Park JH, Yoon DM, Lee YC, Kim WO, Yoon KB. 10 Times Epidural Blood Patches for Spontaneous Intracranial Hypotension -A case report-. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.1.60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Joon Hee Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Duck Mi Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Chang Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Won Oak Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Bong Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Hayek SM, Fattouh M, Dews T, Kapural L, Malak O, Mekhail N. Successful treatment of spontaneous cerebrospinal fluid leak headache with fluoroscopically guided epidural blood patch: a report of four cases. PAIN MEDICINE 2004; 4:373-8. [PMID: 14750917 DOI: 10.1111/j.1526-4637.2003.03037.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Spontaneous cerebrospinal fluid (CSF) leak is a rare clinical entity that may result in disabling headaches. It occurs as a result of dural defects, and the initial symptoms resemble those of postdural puncture headache. However, the positional headache can later evolve into a persistent chronic daily headache. The diagnosis of spontaneous CSF leak can be very challenging, but increasing awareness and improved diagnostic techniques are yielding ever more cases. When conservative management fails, the pain management clinician is called upon to administer an epidural blood patch. The success of this technique is dependent upon accurate diagnosis of the site of leakage and targeted epidural administration of the blood patch to this area. In this report, we describe four consecutive cases that were referred to our pain management department over an 18-month period and were successfully treated with site-directed epidural blood patches.
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Affiliation(s)
- Salim M Hayek
- Department of Pain Management, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Ong B, Fong W. Spontaneous Cervical Spine Cerebrospinal Fluid Leak With Resultant Intracranial Hypotension. Clin Nucl Med 2003; 28:916-9. [PMID: 14578709 DOI: 10.1097/01.rlu.0000093088.32615.d7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Benjamin Ong
- Nuclear Medicine Department, Royal Brisbane Hospital, Herston, Queensland, Australia
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Schievink WI, Jacques L. Recurrent Spontaneous Spinal Cerebrospinal Fluid Leak Associated with “Nude Nerve Root” Syndrome: Case Report. Neurosurgery 2003; 53:1216-8; discussion 1218-9. [PMID: 14580290 DOI: 10.1227/01.neu.0000089483.30857.11] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2002] [Accepted: 06/24/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE
Spontaneous spinal cerebrospinal fluid (CSF) leaks have been noted occasionally at multiple sites in the same patient, but recurrent spontaneous spinal CSF leaks have not been documented. We describe a patient with a recurrent CSF leak who was found at surgery to have an absence of the entire nerve root sleeve at multiple thoracic levels.
CLINICAL PRESENTATION
A 29-year-old woman bodybuilder noted an excruciating orthostatic headache associated with nausea. The neurological examination was unremarkable, and a magnetic resonance imaging examination showed the typical changes of intracranial hypotension. Computed tomographic myelography showed an extensive bilateral lower cervical CSF leak.
INTERVENTION
The patient underwent bilateral lower cervical nerve root explorations, and several small dural holes were found. The CSF leaks were repaired, but 3 months later, computed tomographic myelography showed a new CSF leak in the midthoracic area. A thoracic laminectomy was performed, and several nerve roots were found to be completely devoid of dura. After the CSF leaks were repaired, there was significant improvement in her headaches.
CONCLUSION
A recurrent spontaneous spinal CSF leak may occur in patients with intracranial hypotension at a site previously documented not to be associated with a CSF leak. Absent nerve root sleeves may be found in patients with spontaneous spinal CSF leaks (“nude nerve root” syndrome), and these patients may be at increased risk of developing a recurrent CSF leak.
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Affiliation(s)
- Wouter I Schievink
- Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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Schievink WI, Maya MM, Riedinger M. Recurrent spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension: a prospective study. J Neurosurg 2003; 99:840-2. [PMID: 14609162 DOI: 10.3171/jns.2003.99.5.0840] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Intracranial hypotension due to a spontaneous spinal cerebrospinal fluid (CSF) leak is an increasingly recognized cause of postural headaches, but reliable follow-up data are lacking. The authors undertook a study to determine the risk of a recurrent spontaneous spinal CSF leak.
Methods. The patient population consisted of a consecutive group of 18 patients who had been evaluated for consideration of surgical repair of a spontaneous spinal CSF leak. The mean age of the 15 women and three men was 38 years (range 22–55 years). The mean duration of follow up was 36 months (range 6–132 months). The total follow-up time was 654 months. A recurrent spinal CSF leak was defined on the basis of computerized tomography myelography evidence of a CSF leak in a previously visualized but unaffected spinal location. Five patients (28%) developed a recurrent spinal CSF leak; the mean age of these four women and one man was 36 years. A recurrent CSF leak developed in five (38%) of 13 patients who had undergone surgical CSF leak repair, compared with none (0%) of five patients who had been treated non-surgically (p = 0.249). The recurrent leak occurred between 10 and 77 months after the initial CSF leak, but within 2 or 3 months of successful surgical repair of the leak in all patients.
Conclusions. Recurrent spontaneous spinal CSF leaks are not rare, and the recent successful repair of such a leak at another site may be an important risk factor.
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Affiliation(s)
- Wouter I Schievink
- Maxine Dunitz Neurosurgical Institute, Imaging Medical Group, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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Lin WC, Lirng JF, Fuh JL, Wang SJ, Chang FC, Ho CF, Teng MMH, Chang CY. MR findings of spontaneous intracranial hypotension. Acta Radiol 2002. [DOI: 10.1034/j.1600-0455.2002.430304.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bai J, Yokoyama K, Kinuya S, Konishi S, Michigishi T, Tonami N. Radionuclide cisternography in intracranial hypotension syndrome. Ann Nucl Med 2002; 16:75-8. [PMID: 11922213 DOI: 10.1007/bf02995297] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 44-year-old male patient complaining of severe headache right after twisting his body during aerobic exercises in a swimming pool underwent In-111 DTPA radionuclide cisternography. Leakage of cerebrospinal fluid (CSF) was proved on the right side of T2 and T3 vertebrae. Cisternography after bed and conservative treatments demonstrated the disappearance of abnormal tracer accumulations. Radionuclide cisternography is of great value in diagnosing cerebral-spinal fluid leak and in evaluating the therapeutic effect.
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Affiliation(s)
- Jingming Bai
- Department of Biotracer Medicine, Graduate School of Medical Sciences, Kanazawa University, Japan.
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