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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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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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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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4
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Wang Y, Shen X, Wang P, Fang Q. Clinical characteristics of cerebral venous sinus thrombosis patients with new-onset of headache. BMC Neurol 2023; 23:56. [PMID: 36732686 PMCID: PMC9893575 DOI: 10.1186/s12883-023-03098-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE This study aimed to assess the clinical characteristics of cerebral venous sinus thrombosis (CVT) patients with new-onset headache and to identify the risk factors for headache in this population. METHODS We retrospectively reviewed the demographic and clinical data of 69 CVT patients recruited between September 2017 and September 2019. Patients were classified into two groups, the headache group and the non-headache group, according to the presence or absence of new-onset headache symptoms at admission. The following characteristics and parameters were measured and analyzed, including gender, age, amount of thromboembolic cerebral venous sinus(ATCVS), and other relevant indicators. RESULTS The incidence of headache was 75% in this cohort. The proportion of female patients in the headache group was higher than that in the non-headache group. Patients in the headache group were younger than those without headache. CVT patients of headache group showed higher lymphocyte ratio (LR), blood urea nitrogen (BUN), and intracranial pressure (ICP) compared to the non-headache group, whereas mean corpuscular volume (MCV) and levels of protein (cerebrospinal fluid, CSF) and lactic dehydrogenase (LDH) in CSF were lower in headache patients. The data also revealed younger age and the increased level of chloride ion CI-(CSF) were the risk factors for the occurrence of headache in CVT patients. CONCLUSION Age, LR, MCV, BUN levels, ICP, protein (CSF), and LDH (CSF) in patients with headache were significantly different from those in the non-headache group at admission. Younger age and a level of CI- (CSF) were risk factors for headache in CVT patients. These findings may provide guidance for clinical diagnosis and treatment of CVT.
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Affiliation(s)
- Yugang Wang
- grid.429222.d0000 0004 1798 0228Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu China ,Department of Neurology, The First People’s Hospital of XianYang, XianYang, Sha’anxi China
| | - Xiaozhu Shen
- grid.440299.2Department of Neurology, The Second People’s Hospital of Lian Yun Gang, Lian Yun Gang, Jiangsu, China
| | - Ping Wang
- grid.412478.c0000 0004 1760 4628Department of Neurology, The First People’s Hospital of He Fei, He Fei, An’Hui China
| | - Qi Fang
- grid.429222.d0000 0004 1798 0228Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu China
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Moreira DG, Félix EPV, Onishi FJ, Ferraz HB, Coradine TLC, Braga VL, Oliveira EMLD. Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:128-133. [PMID: 36863400 PMCID: PMC10033192 DOI: 10.1055/s-0042-1758752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT). OBJECTIVE To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward. METHODS Review of the medical files of three patients and description of clinical and surgical outcomes. RESULTS Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with laminoplasty. Both of them had uneventful recovery and remission in surgery follow-up. CONCLUSION The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.
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Affiliation(s)
- Daniel Gabay Moreira
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Franz Jooji Onishi
- Universidade Federal de São Paulo, Departamento de Neurocirurgia, São Paulo SP, Brazil
| | | | | | - Vinícius Lopes Braga
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
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6
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M O, JK CG, I G, NR K, CM C, W B. Prevalence of cerebral vein thrombosis among patients with spontaneous intracranial hypotension. Interv Neuroradiol 2022; 28:719-725. [PMID: 34904470 PMCID: PMC9706257 DOI: 10.1177/15910199211065912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/17/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Cerebral venous sinus thrombosis (CVST) is a rare condition but an important complication of spontaneous intracranial hypotension (SIH). We reviewed our experience of patients with SIH and assessed for the presence of CVST. METHODS We reviewed the medical records and imaging studies from our tertiary referral institution, assessing patients with clinically suspected SIH as well as imaging findings of intracranial hypotension. All relevant brain MRIs were reviewed for the presence of brain sag, pachymeningeal enhancement, and CVST. RESULTS Among 563 patients with a clinical diagnosis of SIH, 431 (76%) demonstrated brain sag. In the overall patient cohort, a total of 5 patients had CVST (0.9%) and all 5 of these patients demonstrated findings of brain sag. Of the patients with CVST, 3 had significant complications, including dural arteriovenous fistulas (2 patients) and lobar hemorrhage with seizure (1 patient). CONCLUSION SIH is a risk factor for the development of CVST. In our review of 563 patients with clinical and/or imaging findings of SIH, 0.9% of patients were diagnosed with CVST and 3 of these patients (60%) had additional severe complications.
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Affiliation(s)
- Oien M
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Garza I
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Kissoon NR
- Neurology, Mayo Clinic, Rochester, MN, USA
| | - Carr CM
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Brinjikji W
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
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Caranzano L, Fenter H, Maeder P, Michel P, Strambo D. Pearls & Oy-sters: Postdural Puncture Headache, Cerebral Sinus Venous Thrombosis, and Reversible Cerebral Vasoconstriction Syndrome in the Peripartum Period. Neurology 2022; 99:665-668. [PMID: 35948451 DOI: 10.1212/wnl.0000000000201111] [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: 12/31/2021] [Accepted: 06/30/2022] [Indexed: 11/15/2022] Open
Abstract
We report the case of a 34-year-old female patient complaining of headaches 1 day after childbirth, initially interpreted as postdural puncture headache (PDPH) and treated successfully with an epidural blood patch. Five days later, she presented with an acute proportional right sensorimotor hemisyndrome and a new-onset left-sided headache, attributed to a venous stroke from left-sided cerebral sinus venous thrombosis (CSVT). Simultaneously, we found radiologic signs of reversible cerebral vasoconstriction syndrome (RCVS), considered asymptomatic. We administered anticoagulant therapy to the patient, and she showed full motor recovery at 3-month clinical follow-up. PDPH, CSVT, and RCVS are well-known neurologic complications during the peripartum period. All 3 conditions present with headaches, and headache features may overlap, masking co-occurrence and making accurate diagnosis (differentiation) of these diseases difficult. Each disease can potentially lead to disabling deficits, but all respond to specific treatment. Knowledge of the causes of headaches in the peripartum period, their specific clinical characteristics, and potential complications helps to prioritize and interpret diagnostic tests to offer appropriate therapy.
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Affiliation(s)
- Leonardo Caranzano
- From the Department of Clinical Neurosciences (L.C., H.F., P. Michel, D.S.), Neurology Service, and Department of Medical Radiology (P. Maeder), Radiodiagnostic and Interventional Radiology Service, Lausanne University Hospital and University of Lausanne, Switzerland.
| | - Helene Fenter
- From the Department of Clinical Neurosciences (L.C., H.F., P. Michel, D.S.), Neurology Service, and Department of Medical Radiology (P. Maeder), Radiodiagnostic and Interventional Radiology Service, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Philippe Maeder
- From the Department of Clinical Neurosciences (L.C., H.F., P. Michel, D.S.), Neurology Service, and Department of Medical Radiology (P. Maeder), Radiodiagnostic and Interventional Radiology Service, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Patrik Michel
- From the Department of Clinical Neurosciences (L.C., H.F., P. Michel, D.S.), Neurology Service, and Department of Medical Radiology (P. Maeder), Radiodiagnostic and Interventional Radiology Service, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Davide Strambo
- From the Department of Clinical Neurosciences (L.C., H.F., P. Michel, D.S.), Neurology Service, and Department of Medical Radiology (P. Maeder), Radiodiagnostic and Interventional Radiology Service, Lausanne University Hospital and University of Lausanne, Switzerland
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Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [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: 12/02/2022]
Abstract
INTRODUCTION Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed. AREAS COVERED The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes. EXPERT OPINION The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.
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Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Zhang D, Chen Y, Wang J, Hu X. Intracranial hypotension as a contributor to isolated cortical vein thrombosis. Headache 2022; 62:212-219. [PMID: 35137399 DOI: 10.1111/head.14254] [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: 05/11/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Isolated cortical vein thrombosis (ICVT), a rare type of cerebral venous thrombosis (CVT), is diagnostically challenging in some cases, and intracranial hypotension (IH) is known to cause CVT. METHODS In this study, we reviewed the clinical and imaging characteristics of ICVT in patients with IH caused by spinal cerebrospinal fluid leakage, based on a literature review and investigation of cases from our hospital. RESULTS Between January 1, 2007, and November 1, 2019, 735 patients were diagnosed with IH at our hospital; three patients developed ICVT (incidence ~ 0.4%, 3/735), and the literature review yielded an additional 23 cases. Therefore, 26 patients (mean age 35.9 ± 11.4 years old) were included in this study. The most common symptoms were headache (100.0%, 26/26), focal neurological deficits (53.8%, 14/26), and seizure (34.6%, 9/26). The initial headache was orthostatic in 96.2% (25/26) of patients, and 38.5% (10/26) of patients reported a change in the headache pattern following diagnosis of ICVT. Neuroimaging findings associated with ICVT included the cord sign (61.5%, 16/26) and parenchymal brain lesions (46.2%, 12/26), such as intracerebral hemorrhage (30.8%, 8/26), hemorrhagic infarcts (11.5%, 3/26), and localized edema (11.5%, 3/26). The percentage of patients who received anticoagulation and epidural blood patch therapy was similar (69.2% [18/26] vs. 65.4% [17/26]), and most patients recovered completely (92.3%, 24/26). CONCLUSION IH should be considered in the differential diagnosis in patients with ICVT. Knowledge of the relevant clinical and neuroimaging features is important to facilitate early diagnosis for favorable prognosis.
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Affiliation(s)
- Dan Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Yin Chen
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Jin Wang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Xingyue Hu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
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Yokoya S, Oka H, Hino A. Cerebral venous thrombosis following spontaneous intracranial hypotension diagnosed by craniotomy: A case report and diagnostic pitfalls. Surg Neurol Int 2021; 12:367. [PMID: 34513134 PMCID: PMC8422431 DOI: 10.25259/sni_546_2021] [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: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Cerebral vein and dural sinus thrombosis (CVT) is a rare but important complication of spontaneous intracranial hypotension (SIH). The diagnosis is difficult in cases lacking typical symptoms and typical imaging findings. Case Description: A 29-year-old male patient with a seizure attack was admitted to our hospital. Based on the head imaging findings, we misdiagnosed the patient with primary cerebral parenchymal lesion and performed an open biopsy. However, during the procedure, the patient was diagnosed with low cerebrospinal fluid pressure and cerebral cortical vein thrombosis. Conclusion: Thus, CVT due to SIH should be considered as a probable cause of secondary parenchymal lesions.
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Affiliation(s)
- Shigeomi Yokoya
- Department of Neurosurgery, Saiseikai Shiga Hospital, Ritto, Shiga, Japan
| | - Hideki Oka
- Department of Neurosurgery, Saiseikai Shiga Hospital, Ritto, Shiga, Japan
| | - Akihiko Hino
- Department of Neurosurgery, Saiseikai Shiga Hospital, Ritto, Shiga, Japan
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11
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Ferrante E, Trimboli M, Petrecca G, Allegrini F. Cerebral venous thrombosis in spontaneous intracranial hypotension: A report of 8 cases and review of the literature. J Neurol Sci 2021; 425:117467. [PMID: 33894614 DOI: 10.1016/j.jns.2021.117467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/30/2021] [Accepted: 04/16/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The occurrence of cerebral venous thrombosis (CVT) in patients with spontaneous intracranial hypotension (SIH) raises difficult practical questions regarding the management of the two conditions. The first-line therapy for CVT is anticoagulation (AC); however, its potential benefit in SIH/CVT patients, especially if complicated by subdural haematoma, must be carefully evaluated taking account of the intracranial haemorrhage risk. Venous system recanalization and good prognosis in SIH/CVT patients treated with epidural blood patch (EBP), the main treatment option for SIH, have been already described. METHODS We reviewed our cases of SIH complicated by CVT among a cohort of 445 SIH patients observed and treated during the last years. All published case reports and case series reporting patients with SIH and CVT were also ascertained and reviewed. RESULTS Eight (2%) out of 445 patients suffering with SIH, were also diagnosed with CVT. All patients observed had orthostatic headache, three of them experienced a change in their headache pattern over the SIH course. Six out of eight patients received both AC and EBP treatments. Two patients were treated using only AC or EBP. A bilateral subdural haematoma enlargement after 1 month of AC was observed in one case. Complete CVT recanalization after treatment was obtained in three patients, including two with multiple CVT at baseline; partial CVT recanalization was achieved in two patients. Three patients experienced no CVT recanalization. After 6-48 months' follow-up all patients were still asymptomatic. CONCLUSIONS The use of AC therapy should be weighed against the intracranial haemorrage risk and should be monitored carefully if initiated. Effective and prompt EBP, even without AC therapy, might lead to a good prognosis in selected cases.
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Affiliation(s)
- Enrico Ferrante
- Neurology Department, AOR San Carlo, Potenza (IT), Italy; Neurology Department, Alto Vicentino Hospital, AULSS 7 Pedemontana, Santorso (IT), Italy; Neurology Department, Niguarda Ca Granda Hospital, Milan (IT), Italy.
| | - Michele Trimboli
- Neurology Department, AOR San Carlo, Potenza (IT), Italy; Institute of Neurology Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro (IT), Italy.
| | | | - Francesco Allegrini
- Anesthesiology and Intensive Care Department, AOR San Carlo, Potenza (IT), Italy
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12
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Cerebral venous thrombosis due to spontaneous intracranial hypotension: Reperfusion after epidural blood patch only. Rev Neurol (Paris) 2021; 177:1039-1041. [PMID: 33648781 DOI: 10.1016/j.neurol.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 11/21/2022]
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13
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Pensato U, Giammello F, Baldini T, Zaniboni A, Piccolo L, Arnone G, Gentile M, Cirillo L, Simonetti L, Isceri S, Zini A. The domino effect of acephalgic spontaneous intracranial hypotension. Neurol Sci 2020; 42:309-312. [PMID: 32989589 DOI: 10.1007/s10072-020-04755-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
Spontaneous intracranial hypotension results from a spinal CSF leak and usually presents with orthostatic headache, although acephalgic presentations have anecdotally been reported. The underlying low CSF volume, rarely, leads to serious complications such as cerebral venous thrombosis and coma. We report a patient presenting with cerebral venous thrombosis secondary to acephalgic spontaneous intracranial hypotension. An epidural blood patch was performed; nonetheless, the patient intracracal condition deteriorated to coma and neuroimages showed a deep brain swelling with midbrain distortion, subsequently complicated by intracranial pontine hemorrhage.
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Affiliation(s)
- Umberto Pensato
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Fabrizio Giammello
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Tommaso Baldini
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Anna Zaniboni
- Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Laura Piccolo
- Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Giorgia Arnone
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Mauro Gentile
- Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Luigi Cirillo
- Neuroradiology Unit, Bellaria Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,DIMES, Department of Specialty, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - Luigi Simonetti
- Neuroradiology Unit, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Salvatore Isceri
- Neuroradiology Unit, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Nigrisoli 2, 40133, Bologna, Italy.
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14
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Paris D, Rousset D, Bonneville F, Fabre N, Faguer S, Huguet-Rigal F, Larcher C, Martin C, Osinski D, Gaussiat F, Delamarre L, Brauge D, Fourcade O, Geeraerts T, Mrozek S. Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report. Headache 2020; 60:2583-2588. [PMID: 32990351 DOI: 10.1111/head.13977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH. METHODS Case report. CASE DESCRIPTION We report here a case of comatose patient due to spontaneous IH complicated by CVT and subdural hemorrhage. The correct diagnosis was delayed due to many confounding factors. IH was suspected after subdural hemorrhage recurrence and confirmed by magnetic resonance imaging (MRI). After 2 epidural patches with colloid, favorable outcome was observed. DISCUSSION The most common presentation of IH is postural orthostatic headaches. In the present case report, the major clinical signs were worsening of consciousness and coma, which are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within the brain. CONCLUSION Association of CVT and subdural hemorrhage should lead to suspect IH. Brain imaging can help and find specific signs of IH.
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Affiliation(s)
- Diane Paris
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - David Rousset
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Fabrice Bonneville
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Nelly Fabre
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Stanislas Faguer
- Department of Nephrology, Dialysis and Multi-Organ Transplantation, Toulouse University Hospital, Toulouse, France
| | - Françoise Huguet-Rigal
- Department of Hematology, University Institute of Cancer of Toulouse-Oncopole, Toulouse, France
| | - Claire Larcher
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Charlotte Martin
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Diane Osinski
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - François Gaussiat
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Louis Delamarre
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - David Brauge
- Department of Neurosurgery, University Hospital of Toulouse, Toulouse, France
| | - Olivier Fourcade
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Ségolène Mrozek
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
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15
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Ferrante E, Trimboli M, Petrecca G, Allegrini F, Ferrante MM, Rubino F. Management of Spontaneous Intracranial Hypotension During Pregnancy: A Case Series. Headache 2020; 60:1777-1787. [DOI: 10.1111/head.13942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Enrico Ferrante
- Neurology Department AOR San Carlo Potenza Italy
- Neurology Department Alto Vicentino Hospital – AULSS 7 Pedemontana Santorso Italy
| | - Michele Trimboli
- Neurology Department AOR San Carlo Potenza Italy
- Department of Medical and Surgical Sciences Institute of Neurology AOU Mater Domini – Magna Græcia University Catanzaro Italy
| | - Giuseppe Petrecca
- Anesthesiology and Intensive Care Department AOR San Carlo Potenza Italy
| | | | | | - Fabio Rubino
- Palliative Care and Pain Management Department ASST Valtellina Sondrio Italy
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16
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Yamamoto A, Hattammaru Y, Uezono S. Spontaneous intracranial hypotension associated with cerebral venous thrombosis detected by a sudden seizure: a case report. JA Clin Rep 2020; 6:59. [PMID: 32754800 PMCID: PMC7403223 DOI: 10.1186/s40981-020-00362-3] [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: 05/10/2020] [Accepted: 07/16/2020] [Indexed: 11/14/2022] Open
Abstract
Background Spontaneous intracranial hypotension (SIH) is rare but can lead to life-threatening complications including cerebral venous thrombosis (CVT). The concurrence of CVT and SIH raises questions regarding priority. Case presentation We present the case of a 52-year-old woman who developed sudden left-sided hemiparesis and generalized tonic-clonic seizures. She experienced progressive orthostatic headaches over the prior 2 weeks. Imaging showed thrombosis in the left transverse and sigmoid sinuses, bilateral subdural hematomas, and a cervicothoracic cerebrospinal fluid leak. Low molecular weight heparin was administered, but it was discontinued 2 days later due to subarachnoid hemorrhage. She was transferred to our hospital where an epidural blood patch was applied immediately, which resulted in complete symptom relief. Conclusion CVT is a rare complication of SIH that may result in devastating consequences. Treatment of SIH should be the primary focus. Prompt diagnosis and EBP application can result in a good outcome.
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Affiliation(s)
- Atsuko Yamamoto
- Division of Outpatient Pain Clinic, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Yoshiyasu Hattammaru
- Division of Outpatient Pain Clinic, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Shoichi Uezono
- Division of Outpatient Pain Clinic, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan
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17
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Yamamoto Y, Yamamoto N, Fujita K, Fukumoto T, Murakami N, Mure H, Kanematsu Y, Takagi Y, Izumi Y. Cerebral Venous Thrombosis: An Unexpected Complication with Cerebrospinal Fluid Leaks after a Fall in a Patient with Spinocerebellar Ataxia Type 6. Intern Med 2020; 59:1749-1753. [PMID: 32238726 PMCID: PMC7434543 DOI: 10.2169/internalmedicine.4388-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 65-year-old woman with spinocerebellar ataxia presented with generalized seizures due to subcortical hemorrhaging. Magnetic resonance imaging (MRI) revealed obstruction of the superior sagittal sinus. Despite treatment, she became comatose. MRI newly revealed subdural fluid collection and descent of the brainstem. Her history indicated a recent fall, prompting additional studies, which revealed lumbar fracture and cerebrospinal fluid (CSF) leaks. We performed an epidural blood patch, and her consciousness was fully restored in one month. This is the first report of cerebral venous thrombosis with CSF leaks in the lumbar region due to a fall injury.
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Affiliation(s)
- Yuki Yamamoto
- Department of Neurology, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Nobuaki Yamamoto
- Department of Neurology, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Koji Fujita
- Department of Neurology, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Tatsuya Fukumoto
- Department of Neurology, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Nagahisa Murakami
- Department of Neurology, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Hideo Mure
- Department of Neurosurgery, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Yasuhisa Kanematsu
- Department of Neurosurgery, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, University of Tokushima Graduate School of Biomedical Sciences, Japan
| | - Yuishin Izumi
- Department of Neurology, University of Tokushima Graduate School of Biomedical Sciences, Japan
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18
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Bond KM, Benson JC, Cutsforth-Gregory JK, Kim DK, Diehn FE, Carr CM. Spontaneous Intracranial Hypotension: Atypical Radiologic Appearances, Imaging Mimickers, and Clinical Look-Alikes. AJNR Am J Neuroradiol 2020; 41:1339-1347. [PMID: 32646948 DOI: 10.3174/ajnr.a6637] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/30/2020] [Indexed: 12/19/2022]
Abstract
Spontaneous intracranial hypotension is a condition characterized by low CSF volume secondary to leakage through a dural defect with no identifiable cause. Patients classically present with orthostatic headaches, but this symptom is not specific to spontaneous intracranial hypotension, and initial misdiagnosis is common. The most prominent features of spontaneous intracranial hypotension on intracranial MR imaging include "brain sag" and diffuse pachymeningeal enhancement, but these characteristics can be seen in several other conditions. Understanding the clinical and imaging features of spontaneous intracranial hypotension and its mimickers will lead to more prompt and accurate diagnoses. Here we discuss conditions that mimic the radiologic and clinical presentation of spontaneous intracranial hypotension as well as other disorders that CSF leaks can imitate.
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Affiliation(s)
- K M Bond
- From the Mayo Clinic School of Medicine (K.M.B.), Rochester, Minnesota
| | - J C Benson
- Departments of Radiology (J.C.B., D.K.K., F.E.D., C.M.C.)
| | | | - D K Kim
- Departments of Radiology (J.C.B., D.K.K., F.E.D., C.M.C.)
| | - F E Diehn
- Departments of Radiology (J.C.B., D.K.K., F.E.D., C.M.C.)
| | - C M Carr
- Departments of Radiology (J.C.B., D.K.K., F.E.D., C.M.C.)
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19
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Cerebral Venous Sinus Thrombosis Manifesting as a Recurrent Spontaneous Subdural Hematoma: A Case Report. Int J Surg Case Rep 2020; 67:223-226. [PMID: 32066113 PMCID: PMC7025970 DOI: 10.1016/j.ijscr.2020.01.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/16/2020] [Accepted: 01/28/2020] [Indexed: 11/24/2022] Open
Abstract
Cerebral sinus venous thrombosis is a rare cause for a subdural hematoma and should be considered in the differential diagnosis of such cases. Neuroradiological imaging has a valuable role in diagnosing and follow-up of patients. Management of subdural hematoma secondary to venous sinus thrombosis could be challenging due to the controversy in using anticoagulation medications.
Background Diagnosing cerebral sinus venous thrombosis (CSVT) manifested as a spontaneous subdural hematoma (SDH) is challenging due to variability of its clinical features. The neuroradiological investigation is crucial to confirm the diagnosis. The management of SDH secondary to CVST is controversial and not well established. Case description We present a case of an adult man with Down’s syndrome who underwent a left-sided craniotomy and evacuation of spontaneous subdural hematoma. Post-surgery magnetic resonance venography (MRV) revealed venous sinus thrombosis in the right transverse sinus with loss of flow signal. He was started on Apixaban two weeks post-surgery. Three months later, the patient re-presented with recurrence of the SDH. His anticoagulation was discontinued, and he underwent craniotomy reopening and evacuation of the recurrent hematoma. The patient returned to his baseline following this procedure. The patient was followed up in the out-patient clinic regularly. Interval brain MRI and MRV performed at six months showed further resolution of the thrombosis of the right sigmoid sinus with restoration of the venous flow. Conclusion The management of SDH complicating CVST remains controversial due to the rarity of its presentation and the hazards associated with the use of anticoagulation.
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20
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Kim MO, Kim J, Kang J, Kim CH, Kim YS, Kang H, Choi NC, Kwon OY, Kim SK. Spontaneous Intracranial Hypotension as a Cause of Subdural Hematoma in a Patient with Cerebral Venous Thrombosis on Anticoagulation Treatment. J Clin Neurol 2020; 16:327-329. [PMID: 32319252 PMCID: PMC7174105 DOI: 10.3988/jcn.2020.16.2.327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 01/29/2023] Open
Affiliation(s)
- Min Ok Kim
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Juhyeon Kim
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Jongsoo Kang
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Chang Hun Kim
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Young Soo Kim
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Heeyoung Kang
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Nack Cheon Choi
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Oh Young Kwon
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Soo Kyoung Kim
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea.
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