1
|
Bozer JJ, Helfrich KM, Seidler GR, Garrett AL, Hussain N. A Case of a Cerebrospinal Fluid Leak Secondary to Chiropractic Manipulation of the Thoracic Spine. A A Pract 2024; 18:e01844. [PMID: 39248364 DOI: 10.1213/xaa.0000000000001844] [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: 09/10/2024]
Abstract
Chiropractic spinal manipulation therapy (CSMT) of the cervical spine has been reported to cause mechanical dural injuries that result in cerebrospinal fluid (CSF) leaks. We present a case of symptomatic intracranial hypotension after isolated thoracic CSMT. Initial imaging was unable to definitively localize the CSF leak, but dynamic imaging was able to better identify the defect. Multiple epidural blood patches were attempted, including image-guided approaches and with fibrin sealant, but surgical repair was ultimately required. Our case illustrates the risk of dural tear in the setting of recent CSMT and the challenges of managing such an injury.
Collapse
Affiliation(s)
- Jordan J Bozer
- From the Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | | | | |
Collapse
|
2
|
Huang H, Wei TT, Niu ZF, Yu L, He FF. Case report: Epidural blood patches are effective in treating intracranial hypotension due to a subarachnoid-pleural fistula. Front Surg 2022; 9:936949. [PMID: 36238858 PMCID: PMC9551272 DOI: 10.3389/fsurg.2022.936949] [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: 07/05/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background Intracranial hypotension (IH) is usually associated with cerebrospinal fluid (CSF) leakage and/or CSF hypotension, and epidural blood patch (EBP) therapy has been proven to be effective for treating spontaneous IH and post-dural puncture headaches. Tarlov cysts (TCs) are common lesions of the sacral spine. They have rarely been reported in thoracic locations and are even less common in the posterior mediastinum, which can lead to their misdiagnosis as neurogenic tumors. Case presentation Here, we report the case of a 60-year-old woman who developed an orthostatic headache after the thoracoscopic resection of a TC in the posterior mediastinum that was presumed to be a schwannoma preoperatively. The patient was finally diagnosed with IH caused by a subarachnoid-pleural fistula (SPF) and was cured by targeted EBP treatment. Conclusion This is a case to show that a single targeted EBP treatment is effective for a patient with IH caused by an SPF after thoracoscopic resection of a TC. This case reminds us to be vigilant that a TC may be masquerading as a posterior mediastinal neurogenic tumor, and a detailed examination should be performed to identify it before deciding on a surgical procedure. In addition, postural headache after thoracoscopic spinal surgery should be alert to the possibility of IH induced by an SPF. Once it occurs, early treatment is necessary, and targeted EBP treatment can serve as a safe and effective alternative when conservative treatment fails.
Collapse
Affiliation(s)
- Hua Huang
- Department of Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ting-Ting Wei
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhong-Feng Niu
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Liang Yu
- Department of Quality Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fei-Fang He
- Department of Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Correspondence: Fei-Fang He
| |
Collapse
|
3
|
Vukovic‐Cvetkovic V, Schytz HW. Airplane flights triggering spontaneous intracranial hypotension: Observations from the Danish headache centre. Acta Neurol Scand 2022; 146:92-98. [PMID: 35502151 PMCID: PMC9321836 DOI: 10.1111/ane.13626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/09/2022] [Accepted: 04/18/2022] [Indexed: 12/02/2022]
Abstract
Objective Spontaneous intracranial hypotension (SIH) manifests as orthostatic headache, which can be confirmed by radiological signs of low intracranial pressure on magnetic resonance imaging of the brain. The most common mechanisms of SIH are ruptured meningeal diverticula, ventral dural tears and CSF‐venous fistulas. SIH is associated with connective tissue disorders, and cases of SIH onset after trivial trauma have been reported. As SIH is often underdiagnosed, the aim of this study is to identify possible new risk factors of SIH onset in a case series of SIH patients. Materials and methods We retrospectively reviewed the medical records of 36 patients diagnosed with SIH. We reviewed and identified potential factors that led to or presented at headache onset in SIH patients. Results We identified 4/36 (11%) patients that had a close temporal relationship between the onset of SIH symptoms and airplane travel. In all four patients, the clinical and imaging features confirmed the diagnosis of SIH. Conclusion This is the first report of a case series of four patients with SIH that could be related to airplane travel. Describing four cases (11%) is not proof but should alert us to a possible causal relationship, which calls for further research. We suggest that when taking medical history, thorough details about the patient's activities, such as headache onset, should be documented because of their importance in correctly diagnosing SIH, which is a debilitating, yet treatable, disease.
Collapse
Affiliation(s)
| | - Henrik W. Schytz
- Danish Headache Center Rigshospitalet‐Glostrup University of Copenhagen Copenhagen Denmark
| |
Collapse
|
4
|
Fernando EZ, Jamora RDG, Torio EF, Mariano MM, Cuanang JR, de Guzman VE. Acute Subdural Hemorrhage as the Initial Presentation of Intracranial Hypotension Following Cervical Chiropractic Manipulation: A Case Report and Systematic Review. Neurohospitalist 2022; 12:57-62. [PMID: 34950387 PMCID: PMC8689553 DOI: 10.1177/1941874420977767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) still remains an underdiagnosed etiology of new-onset headache. Important risk factors include chiropractic manipulation (CM). We present a case of a 36-year-old Filipino woman who presented with severe bifrontal and postural headache associated with dizziness, vomiting, and doubling of vision. A cranial computed tomography scan was done which showed an acute subdural hematoma (SDH) at the interhemispheric area. Pain medications were given which afforded minimal relief. On history, the headaches occurred 2 weeks after cervical CM. Cranial and cervical magnetic resonance imaging revealed findings supportive of intracranial hypotension and neck trauma, respectively. The patient improved with conservative management. We found 12 articles on SIH and CM after a systematic review of literature. Eleven patients (90.9%) initially presented with orthostatic headache. Eight patients (66.7%) were initially treated conservatively but only 5 (62.5%) had complete recovery. Recovery was achieved within 14 days from start of supportive therapy. Among the 3 patients who failed conservative treatment, 2 underwent non-directed epidural blood patch and one required neurosurgical intervention. This report highlights that a thorough history is warranted in patients with new onset headache. A history of CM must be actively sought. The limited evidence from the case reports showed that patients with SIH and SDH but with normal neurologic examination and minor spinal pathology can be managed conservatively for less than 2 weeks. This review showed that conservative treatment in a closely monitored environment may be an appropriate first line treatment.
Collapse
Affiliation(s)
- Emmaline Z. Fernando
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City, Philippines
| | - Roland Dominic G. Jamora
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines,Division of Adult Neurology, Department of Neurosciences, College of Medicine - Philippine General Hospital, University of the Philippines Manila, Manila, Philippines,Roland Dominic G. Jamora, Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines and Division of Adult Neurology, Department of Neurosciences, College of Medicine - Philippine General Hospital, University of the Philippines Manila, Manila, Philippines. Emails: ;
| | - Erickson F. Torio
- Section of Neurosurgery, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
| | - Manuel M. Mariano
- Section of Neurosurgery, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
| | - Joven R. Cuanang
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
| | - Vincent E. de Guzman
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
| |
Collapse
|
5
|
Roytman M, Ulrich CT, Chazen JL. Post-dural puncture pseudomeningocele ("arachnoid bleb"): An underrecognized etiology of spontaneous intracranial hypotension symptomatology. Clin Imaging 2021; 80:377-381. [PMID: 34517304 DOI: 10.1016/j.clinimag.2021.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an important secondary cause of a persistent headache syndrome, classically presenting as sudden onset debilitating positional headaches related to reduced intracranial cerebrospinal fluid (CSF) volume. Current understanding of SIH pathogenesis recognizes three underlying etiologies: dural tear, meningeal diverticulum, and CSF-venous fistula, with a fourth broad category of indeterminate/unknown etiologies. Post-dural puncture headache (PDPH) is a well-known and common complication of dural puncture, typically remitting spontaneously within two weeks of onset or with autologous epidural blood patch, though with some patients developing complex and difficult to manage chronic PDPH. Herein, we present a case of chronic PDPH resulting in SIH symptomatology secondary to a post-dural puncture pseudomeningocele, or "arachnoid bleb," successfully treated with curative surgical intervention. Increasing awareness of additional potential etiologies of SIH symptomatology will allow for improved detection for targeted definitive therapy, ultimately improving patient outcomes including quality of life in this debilitating and difficult to manage secondary headache syndrome.
Collapse
Affiliation(s)
- Michelle Roytman
- Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Medicine, United States of America
| | | | - J Levi Chazen
- Department of Radiology, Hospital for Special Surgery, United States of America.
| |
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW To provide an update on recent developments in the understanding, diagnosis, and treatment of CSF-venous fistula (CVF). RECENT FINDING CVF is a recently recognized cause of spontaneous intracranial hypotension (SIH), an important secondary headache, in which an aberrant connection is formed between the spinal subarachnoid space and an adjacent spinal epidural vein permitting unregulated loss of CSF into the circulatory system. CVFs often occur without a concurrent epidural fluid collection; therefore, CVF should be considered as a potential etiology for patients with SIH symptomatology but without an identifiable CSF leak. Imaging plays a critical role in the detection and localization of CVFs, with a number of imaging techniques and provocative maneuvers described in the literature to facilitate their localization for targeted and definitive treatment. Increasing awareness and improving the localization of CVFs can allow for improved outcomes in the SIH patient population. Future prospective studies are needed to determine the diagnostic performance of currently available imaging techniques as well as their ability to inform workup and guide treatment decisions.
Collapse
Affiliation(s)
- Michelle Roytman
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Gayle Salama
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Matthew S Robbins
- Department of Neurology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - J Levi Chazen
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA.
| |
Collapse
|
7
|
An unusual postural headache: a case report. Chiropr Man Therap 2020; 28:56. [PMID: 33183329 PMCID: PMC7664038 DOI: 10.1186/s12998-020-00347-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper presents a case of an evolving unusual thunderclap headache that presented to a chiropractor. CASE PRESENTATION The intense "migraine-like" headache was aggravated by standing up and relieved substantially when lying down. This low pressure, orthostatic headache was diagnosed as a spontaneous intracranial hypotension (SIH) secondary to a spontaneous tear of the dura. It was referred to the local hospital for management with autogolous blood injection to form an epidural blood patch of the defect. It resolved substantially within 3 days. CONCLUSIONS The significance of key features in the history and examination and how if not recognised and subsequently treated with manual therapy, the dural tear could be attributed to the treatment of the chiropractor, a treatment that would typically involve cervical manipulation. Discussion is provided of the implications of a missed diagnosis and possible subsequent chiropractic management with the evolving SIH being attributed to the chiropractic intervention rather than its true "spontaneous" nature.
Collapse
|
8
|
Abstract
Fistulas are abnormal connections between 2 epithelial-lined structures. Thoracic fistulas may result from nonanatomic communications between spaces within the thorax, such as the lung, tracheobronchial tree, pleural space, and mediastinal structures, or between thoracic spaces and extrathoracic structures, such as the gastrointestinal tract. Furthermore, thoracic fistulas may result in communication between thoracic spaces and the spine or vascular structures. Potential causes include trauma, infection, neoplasm, surgical intervention, or medical syndromes. In this article, we discuss various acquired thoracic fistulas and their potential causes, key multimodality imaging manifestations, and clinical significance.
Collapse
|
9
|
Yang W, Ge M, Chen C, Zeng Q. Diagnose and treatment of traumatic pleural-subarachnoid fistula in children: A case report and systematic review. Chin Neurosurg J 2020; 6:27. [PMID: 32922956 PMCID: PMC7409484 DOI: 10.1186/s41016-020-00204-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 06/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background Pleural-subarachnoid fistula (PSF) is a rare disease that is difficult to diagnose and treat. Secondary intracranial hypertension and the treatment are seldom mentioned previously among PSF. Case presentation A 1-year-old boy diagnosed PSF developed into secondary intracranial hypertension after conservative treatment. He was finally cured by down-step treatment of mannitol, avoiding form ventricle-peritoneal shunt. Then, we reviewed the literature of pleural-subarachnoid fistula. Fifty-six cases have been reported so far. Most of the cases (51.8%) were caused by surgery; only 17.9% were caused by car accidents. Regarding the treatment, half of the cases cured by surgery and the other by conservative measures. Our case is the first one involving secondary intracranial hypertension and cured by down-step treatment of mannitol. Conclusions A comprehensive examination should be performed before the treatment to avoid any inappropriate medical strategies. Secondary acute intracranial hypertension may be cured by down step treatment of mannitol, evading from the long-term ventriculoperitoneal shunt.
Collapse
Affiliation(s)
- Wei Yang
- Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045 China
| | - Ming Ge
- Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045 China
| | - Chenghao Chen
- Department of Thoracic, Beijing Children's Hospital, Capital Medical University, 56 South Lishi Road, Xicheng District, Beijing, 100045 China
| | - Qi Zeng
- Department of Thoracic, Beijing Children's Hospital, Capital Medical University, 56 South Lishi Road, Xicheng District, Beijing, 100045 China
| |
Collapse
|
10
|
Spinal Cerebrospinal Fluid Leakage in Spontaneous Intracranial Hypotension: An Intrathecal Gadolinium Enhanced MR-Myelography Study. J Belg Soc Radiol 2020; 104:6. [PMID: 32025622 PMCID: PMC6993594 DOI: 10.5334/jbsr.1877] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objectives: In the present study, the authors presented the intrathecal gadolinium enhanced MR-myelography findings of patients with spontaneous intracranial hypotension. Materials and Methods: Intrathecal gadolinium enhanced MR-myelography (Gd-MR-myelography) examinations between October 2012 and September 2018 in patients having clinical and radiological findings of spontaneous intracranial hypotension were evaluated retrospectively. Sites and types of contrast leakages in 20 patients who met inclusion criteria were reviewed. All patients had undergone T1-fat suppressed sagittal images of cervical, thoracic and lumbar region after the off label intrathecal injection of 1 ml gadolinium-based contrast agent. Results: Patients (18 female, 2 male) are aged between 23 and 62 years-old (mean age: 41.1). Cerebrospinal fluid (CSF) leakages were cervical in 6 patients, thoracic in 5 patients, lumbar in 5 patients. One patient had leakage in multiple levels on both cervical and thoracic region and another patient on both cervical-thoracic and lumbar regions. No patients had adverse effects related to intrathecal injection of gadolinium. Conclusions: Gd-MR-myelography is effective imaging modality to reveal spinal CSF leakages in patients with spontaneous intracranial hypotension.
Collapse
|
11
|
Federspiel CK, Kelsen J, Fugleholm K. Delayed Iatrogenic Intracranial Hypotension After Thoracotomy. Ann Thorac Surg 2020; 110:e35-e37. [PMID: 31904369 DOI: 10.1016/j.athoracsur.2019.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/27/2019] [Accepted: 11/10/2019] [Indexed: 11/26/2022]
Abstract
We report a case of intracranial hypotension (IH) after thoracotomy. A 56-year-old woman presented 10 days after a left upper lobectomy with severe headache due to pneumocephalus and pneumorrhachis, which resolved on conservative treatment. Two months later, the patient was readmitted in an unconscious state with characteristics of IH and "sagging brain." Subsequent magnetic resonance imaging revealed a fistula at the level of the left Th5 pedicle. The patient underwent operation with closure of the fistula and recovered without complications. The presence of pneumocephalus and pneumorrhachis after thoracotomy should raise the suspicion of a persistent subarachnoid-pleural fistula to prevent IH and "sagging brain."
Collapse
Affiliation(s)
- Christine K Federspiel
- Department of Pulmonary and Infectious Medicine, Nordsjællands Hospital, Hillerød, Denmark.
| | - Jesper Kelsen
- Spine Unit, Department of Orthopedics, Rigshospitalet, København, Denmark
| | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, København, Denmark
| |
Collapse
|
12
|
Tuchin P. Postural Headaches Due to Cerebrospinal Fluid Leakage Through Subarachnoid-Pleural Fistula: A Case Report. Headache 2017; 57:665-666. [DOI: 10.1111/head.13049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 12/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Peter Tuchin
- Chiropractic; Macquarie University; North Ryde Sydney Australia
| |
Collapse
|
13
|
Lin SF, Weng HY. Response to “Postural Headaches Due to Cerebrospinal Fluid Leakage Through Subarachnoid-Pleural Fistula: A Case Report”. Headache 2017; 57:667. [DOI: 10.1111/head.13045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Sheng-Feng Lin
- Department of Neurology; Wan Fang Hospital, Taipei Medical University; Taipei Taiwan
| | - Hsing-Yu Weng
- Department of Neurology, School of Medicine; College of Medicine, Taipei Medical University; Taipei Taiwan
| |
Collapse
|