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Maresca L, Fragale M, Petrella G, Boeris D. Management of post blood patch severe rebound intracranial hypertension by the usage of an external ventricular drain. BMJ Case Rep 2024; 17:e257743. [PMID: 38490699 PMCID: PMC10946380 DOI: 10.1136/bcr-2023-257743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a condition characterised by postural headaches due to low cerebrospinal fluid (CSF) pressure, often stemming from CSF leakage. Diagnosis poses a significant challenge, and the therapeutic approach encompasses both conservative measures and operative interventions, such as the epidural blood patch (EBP). However, EBP carries the potential risk of inducing rebound intracranial hypertension (RIH), subsequently leading to high-pressure headaches. We present a case wherein RIH following EBP was effectively managed through the implementation of an external ventricular drain (EVD) aimed at reducing CSF pressure. The patient improved significantly, underscoring the potential utility, if not necessity, of EVD in carefully selected cases, highlighting the imperative for further research to enhance the management of SIH and optimise EBP-related complications.
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Affiliation(s)
- Leonardo Maresca
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
| | - Maria Fragale
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
- Neurosurgery, University of Rome La Sapienza, Rome, Lazio, Italy
| | - Giacomo Petrella
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
| | - Davide Boeris
- Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy
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Lashkarivand A, Eide PK. The first report on brain sagging dementia caused by a cranial leak: A case report. Front Neurol 2022; 13:1006060. [PMID: 36247781 PMCID: PMC9556835 DOI: 10.3389/fneur.2022.1006060] [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: 07/28/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveBrain Sagging Dementia (BSD) is an increasingly recognized syndrome for which diagnostic criteria recently were proposed. There have been no reports on BSD caused by a cranial leak. Here we present the first report on a patient with BSD caused by a cranial leak.Case descriptionA 60-year old male patient was admitted with a 2-year history of orthostatic headache and gradually progressive cognitive and behavioral changes. Traditional treatments for spontaneous intracranial hypotension, including repeated epidural blood patches, failed. Brain imaging showed severe brain sagging, and intracranial pressure monitoring demonstrated intracranial hypotension. No leakage site was found. His past medical history revealed an accident where a ski pole struck his head at age ten. Due to progressive clinical decline, surgery was pursued. A cranial defect with an accompanying cerebrospinal fluid leak site representing the trauma from his childhood was found and repaired. He also was in need of a ventriculoperitoneal shunt. Following surgery, he improved and recovered completely.DiscussionThis case report illustrates that a cranial leak may cause BSD, even with a “lucid interval” between trauma and symptom debut spanning many years. Moreover, this report validates well the recently proposed BSD diagnostic criteria.
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Affiliation(s)
- Aslan Lashkarivand
- Department of Neurosurgery, Oslo University Hospital – Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital – Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- *Correspondence: Per Kristian Eide ;
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Zetlaoui PJ, Buchheit T, Benhamou D. Epidural blood patch: A narrative review. Anaesth Crit Care Pain Med 2022; 41:101138. [DOI: 10.1016/j.accpm.2022.101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
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Early and Delayed Rebound Intracranial Hypertension following Epidural Blood Patch in a Case of Spontaneous Intracranial Hypotension. Case Rep Neurol Med 2022; 2022:5637276. [PMID: 35340426 PMCID: PMC8956435 DOI: 10.1155/2022/5637276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/08/2022] [Indexed: 01/18/2023] Open
Abstract
Background. Spontaneous intracranial hypotension (SIH) is a secondary headache that has been attributed to a cerebrospinal fluid (CSF) leak. It may resolve spontaneously or require conservative treatment. An epidural blood patch (EBP) with autologous blood is performed in cases exhibiting an inadequate response to conservative methods. Rebound intracranial hypertension (RIH) can develop following an EBP in up to 27% of patients. It is characterized by a change in the headache features and is often accompanied by nausea, blurred vision, and diplopia. Symptoms commonly begin within the first 36 hours, but could develop over days to weeks. It is important to differentiate this rebound phenomenon from unimproved SIH, as the treatment options differ. Case Presentation. Here, we present an interesting case of a patient with SIH who was treated with EBP and developed both immediate RIH after 24 hours and delayed RIH 3 weeks following EBP. Conclusions. Following EBP for treatment of SIH, new onset of headache having a different pattern and location should always be monitored for the occurrence of RIH. A lumbar puncture should be done if the symptoms of elevated CSF pressure become intolerable or if the diagnosis is uncertain. Lack of early diagnosis and treatment and differentiation from SIH can cause complications and could affect the optic nerves.
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Wang TY, Karikari IO, Amrhein TJ, Gray L, Kranz PG. Clinical Outcomes Following Surgical Ligation of Cerebrospinal Fluid-Venous Fistula in Patients With Spontaneous Intracranial Hypotension: A Prospective Case Series. Oper Neurosurg (Hagerstown) 2021; 18:239-245. [PMID: 31134267 DOI: 10.1093/ons/opz134] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 01/30/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid-venous fistula (CVF) is a recently described cause of spontaneous intracranial hypotension (SIH). Surgical ligation of CVF has been reported, but clinical outcomes are not well described. OBJECTIVE To determine the clinical efficacy of surgical ligation for treatment of CVF. METHODS Outcomes metrics were collected in this prospective, single-arm, cross-sectional investigation. Inclusion criteria were as follows: diagnosis of SIH, demonstration of CVF on myelography, and surgical treatment of CVF. Pre- and postoperative headache severity was assessed with the Headache Impact Test (HIT-6), a validated headache scale ranging from 36 (asymptomatic) to 78 (most severe). Patient satisfaction with treatment was measured with Patient Global Impression of Change (PGIC). RESULTS Twenty subjects were enrolled, with mean postoperative follow-up at 16.0 ± 9.7 mo. All CVFs were located in the thoracic region (between T4 and T12). Pretreatment headache severity was high (mean HIT-6 scores 65 ± 6). Surgical treatment resulted in marked improvement in headache severity (mean HIT-6 change of -21 ± -9, mean postoperative HIT-6 of 44 ± 8). Of subjects with baseline headache scores in the most severe category, 83% showed a major improvement in severity (transition to the lowest 2 severity categories) after surgery. All subjects (100%) reported clinically significant levels of satisfaction with treatment (PGIC score 6 or 7); 90% reported the highest level of satisfaction. There were no short- or long-term complications or 30-d readmissions. CONCLUSION Surgical ligation is highly effective for the treatment of SIH due to CVF. Larger controlled trials with longer follow-up period are indicated to better assess its long-term efficacy and safety profile.
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Affiliation(s)
- Timothy Y Wang
- Duke University Department of Neurological Surgery, Durham, North Carolina
| | - Isaac O Karikari
- Duke University Department of Neurological Surgery, Durham, North Carolina
| | | | - Linda Gray
- Duke University Department of Radiology, Durham, North Carolina
| | - Peter G Kranz
- Duke University Department of Radiology, Durham, North Carolina
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Sidpra J, Chhabda S, Oates AJ, Bhatia A, Blaser SI, Mankad K. Abusive head trauma: neuroimaging mimics and diagnostic complexities. Pediatr Radiol 2021; 51:947-965. [PMID: 33999237 DOI: 10.1007/s00247-020-04940-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/13/2020] [Accepted: 12/16/2020] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury is responsible for approximately half of all childhood deaths from infancy to puberty, the majority of which are attributable to abusive head trauma (AHT). Due to the broad way patients present and the lack of a clear mechanism of injury in some cases, neuroimaging plays an integral role in the diagnostic pathway of these children. However, this nonspecific nature also presages the existence of numerous conditions that mimic both the clinical and neuroimaging findings seen in AHT. This propensity for misdiagnosis is compounded by the lack of pathognomonic patterns and clear diagnostic criteria. The repercussions of this are severe and have a profound stigmatic effect. The authors present an exhaustive review of the literature complemented by illustrative cases from their institutions with the aim of providing a framework with which to approach the neuroimaging and diagnosis of AHT.
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Affiliation(s)
- Jai Sidpra
- University College London Medical School, London, UK
| | - Sahil Chhabda
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, UK
| | - Aashim Bhatia
- Department of Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susan I Blaser
- Department of Radiology, Hospital for Sick Children, Toronto, ON, Canada
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK.
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Tatum PS, Anderson E, Kravtsova A, Alnasser O, Hedges T, Green-Laroche DM, Madan N. Rapid Cognitive Decline Secondary to CSF Venous Fistula With Postoperative Rebound Intracranial Hypertension and a Hyperintense Paraspinal Vein Sign Seen Retrospectively. Mil Med 2021; 186:e265-e269. [PMID: 32918812 DOI: 10.1093/milmed/usaa204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/12/2020] [Accepted: 09/12/2020] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
A 56-year-old female with 2 prior Chiari decompressions presented with rapidly progressive cognitive decline. Brain magnetic resonance imaging, computed tomography myelogram, and prone digital subtraction myelography revealed signs of brain sag and left T9 perineural cysts but no cerebrospinal fluid leaks. Symptoms improved after multilevel blood patches but recurred. Lateral decubitus digital subtraction myelography revealed a spinal cerebrospinal fluid venous fistula (SCVF), which resolved after neurosurgeons ligated the nerve root. Rebound headaches with papilledema occurred on postoperative day 9 and then resolved 2 months after acetazolamide was started. A hyperintense paraspinal vein was seen retrospectively on T2-weighted magnetic resonance imaging with Dixon fat suppression sequencing. This case is unique in the acuity of cognitive decline secondary to SCVF. Acetazolamide at the time of treatment may potentially be used as prophylaxis for rebound intracranial hypertension. The hyperintense paraspinal vein may have utility in future diagnosis of SCVF.
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Affiliation(s)
- Peter S Tatum
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Emily Anderson
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Alina Kravtsova
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Osamah Alnasser
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Thomas Hedges
- TUFTS Neuro-Ophthalmology, 260 Tremont Street, 11th Floor, Boston, MA 02111
| | | | - Neel Madan
- TUFTS Department of Radiology, 800 Washington St Box 299, Boston, MA 02111
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Schievink WI, Maya MM, Jean-Pierre S, Moser FG, Nuño M, Pressman BD. Rebound high-pressure headache after treatment of spontaneous intracranial hypotension: MRV study. Neurol Clin Pract 2019; 9:93-100. [PMID: 31041122 PMCID: PMC6461412 DOI: 10.1212/cpj.0000000000000550] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/25/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Rebound high-pressure headaches may complicate treatment of spontaneous intracranial hypotension (SIH), but no comprehensive study of such patients has been reported and little is known about its frequency and risk factors. We therefore studied patients undergoing treatment for SIH and performed magnetic resonance venography (MRV) to assess for cerebral venous sinus stenosis, a risk factor for idiopathic intracranial hypertension. METHODS We studied a consecutive group of patients who underwent treatment for SIH. Rebound high-pressure headache was defined as a reverse orthostatic headache responsive to acetazolamide. MRV was obtained in all patients and lateral sinus stenosis was scored according to the system published by Higgins et al., with 0 being normal and 4 signifying bilateral signal gaps. RESULTS The mean age of the 46 men and 67 women was 45.9 years (range 13-71 years) at the time of onset of SIH. Rebound high-pressure headache was diagnosed in 31 patients (27.4%); 14% of patients with an MRV score of 0, 24% with a score of 1, and 46% with a score of 2 or 3 (p = 0.0092). Also, compared to SIH patients who did not develop rebound high-pressure headaches (n = 82), those with rebound high-pressure headaches were younger, more often female, and more often had an extradural CSF collection on spinal imaging. CONCLUSIONS Rebound high-pressure headache occurs in about one-fourth of patients following treatment of SIH and is more common in those with restriction of cerebral venous outflow.
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Affiliation(s)
- Wouter I Schievink
- Departments of Neurosurgery (WIS, SJ-P) and Imaging (MMM, FGM, BDP), Cedars-Sinai Medical Center, Los Angeles; and Department of Public Health Sciences, Division of Biostatistics (MN), University of California, Davis
| | - M Marcel Maya
- Departments of Neurosurgery (WIS, SJ-P) and Imaging (MMM, FGM, BDP), Cedars-Sinai Medical Center, Los Angeles; and Department of Public Health Sciences, Division of Biostatistics (MN), University of California, Davis
| | - Stacey Jean-Pierre
- Departments of Neurosurgery (WIS, SJ-P) and Imaging (MMM, FGM, BDP), Cedars-Sinai Medical Center, Los Angeles; and Department of Public Health Sciences, Division of Biostatistics (MN), University of California, Davis
| | - Franklin G Moser
- Departments of Neurosurgery (WIS, SJ-P) and Imaging (MMM, FGM, BDP), Cedars-Sinai Medical Center, Los Angeles; and Department of Public Health Sciences, Division of Biostatistics (MN), University of California, Davis
| | - Miriam Nuño
- Departments of Neurosurgery (WIS, SJ-P) and Imaging (MMM, FGM, BDP), Cedars-Sinai Medical Center, Los Angeles; and Department of Public Health Sciences, Division of Biostatistics (MN), University of California, Davis
| | - Barry D Pressman
- Departments of Neurosurgery (WIS, SJ-P) and Imaging (MMM, FGM, BDP), Cedars-Sinai Medical Center, Los Angeles; and Department of Public Health Sciences, Division of Biostatistics (MN), University of California, Davis
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Abstract
A literature search found no clinical trials or guidelines addressing the management of spontaneous intracranial hypotension (SIH). Based on the available literature and expert opinion, we have developed recommendations for the diagnosis and management of SIH. For typical cases, we recommend brain magnetic resonance (MR) imaging with gadolinium to confirm the diagnosis, and conservative measures for up to two weeks. If the patient remains symptomatic, up to three non-directed lumbar epidural blood patches (EBPs) should be considered. If these are unsuccessful, non-invasive MR myelography, radionuclide cisternography, MR myelography with intrathecal gadolinium, or computed tomography with myelography should be used to localize the leak. If the leak is localized, directed EPBs should be considered, followed by fibrin sealant or neurosurgery if necessary. Clinically atypical cases with normal brain MR imaging should be investigated to localize the leak. Directed EBPs can be used if the leak is localized; non-directed EBPs should be used only if there are indirect signs of SIH.
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Kranz PG, Amrhein TJ, Gray L. Rebound intracranial hypertension: a complication of epidural blood patching for intracranial hypotension. AJNR Am J Neuroradiol 2014; 35:1237-40. [PMID: 24407273 PMCID: PMC7965157 DOI: 10.3174/ajnr.a3841] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 11/10/2013] [Indexed: 11/07/2022]
Abstract
Rebound intracranial hypertension is a complication of epidural blood patching for treatment of intracranial hypotension characterized by increased intracranial pressure, resulting in potentially severe headache, nausea, and vomiting. Because the symptoms of rebound intracranial hypertension may bear some similarity to those of intracranial hypotension and literature reports of rebound intracranial hypertension are limited, it may be mistaken for refractory intracranial hypotension, leading to inappropriate management. This clinical report of 9 patients with confirmed rebound intracranial hypertension reviews the clinical characteristics of patients with this condition, emphasizing factors that can be helpful in discriminating rebound intracranial hypertension from refractory spontaneous intracranial hypotension, and discusses treatment.
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Affiliation(s)
- P G Kranz
- From the Department of Radiology (P.G.K., L.G.), Duke University Medical Center, Durham, North Carolina
| | - T J Amrhein
- Department Radiology and Radiological Science (T.J.A.), Medical University of South Carolina, Charleston, South Carolina
| | - L Gray
- From the Department of Radiology (P.G.K., L.G.), Duke University Medical Center, Durham, North Carolina
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Yuh EL, Dillon WP. Intracranial Hypotension and Intracranial Hypertension. Neuroimaging Clin N Am 2010; 20:597-617. [DOI: 10.1016/j.nic.2010.07.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mehta B, Tarshis J. Repeated large-volume epidural blood patches for the treatment of spontaneous intracranial hypotension. Can J Anaesth 2009; 56:609-13. [DOI: 10.1007/s12630-009-9121-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Accepted: 05/15/2009] [Indexed: 11/28/2022] Open
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Case report: spontaneous intracranial hypotension in association with the presence of a false localizing C1-C2 cerebrospinal fluid leak. ACTA ACUST UNITED AC 2008; 70:539-43; discussion 543-4. [DOI: 10.1016/j.surneu.2007.05.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Accepted: 05/16/2007] [Indexed: 11/23/2022]
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Is Early Bladder Activity in Radionuclide Cisternography an Indirect Sign of Spontaneous Intracranial Hypotension or Sequence of Lumbar Puncture? Clin Nucl Med 2007; 32:850-3. [DOI: 10.1097/rlu.0b013e318156bb2d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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