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Patel NP, Brinjikji W. Cerebrospinal Fluid-Venous Fistulas. Neurosurg Clin N Am 2024; 35:311-318. [PMID: 38782524 DOI: 10.1016/j.nec.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Cerebrospinal fluid-venous fistulas (CSFVFs) were first described in 2014 and have since become an increasingly diagnosed cause of spontaneous intracranial hypotension due to increased clinical recognition and advancements in diagnostic modalities. In this review, the authors discuss CSFVF epidemiology, the variety of clinical presentations, the authors' preferred diagnostic approach, recent advancements in diagnostic methods, treatment options, current challenges, and directions of future research.
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Affiliation(s)
- Nitesh P Patel
- Department of Neurosurgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; Department of Radiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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2
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Boddu SP, Goodman BP, VanderPluym JH. Headache rounds: Postural headache in a patient with squamous cell carcinoma. Headache 2023; 63:1186-1192. [PMID: 37635384 DOI: 10.1111/head.14615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/20/2023] [Accepted: 07/28/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Sayi P Boddu
- Mayo Clinic Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Higgins JNP, Kirker S. Case report: Post-traumatic Tourette syndrome resolving with treatment of jugular venous narrowing; reconciling organic brain dysfunction following whiplash trauma with the absence of direct brain injury. Front Neurol 2023; 14:1179596. [PMID: 37342778 PMCID: PMC10277496 DOI: 10.3389/fneur.2023.1179596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/02/2023] [Indexed: 06/23/2023] Open
Abstract
We describe a man aged 33 years who developed multiple symptoms, personality change, and a severe tic disorder following a road traffic accident, which were undiminished for 3 years until jugular venous narrowing between the styloid process of the skull and the transverse process of the C1 vertebra was treated by surgical decompression. Immediately following surgery, his abnormal movements almost completely resolved, with no regression in 5 years of follow-up. Vigorously debated at the time was whether or not his condition represented a functional disorder. Unrecognized throughout his illness, however, was a complaint of intermittent, profuse discharge of clear fluid from his nose that began on the day of the accident and continued up to the time of surgery, after which it was substantially reduced. This outcome reinforces the idea that jugular venous narrowing can cause or perpetuate a cerebrospinal fluid leak. It suggests that the interaction between these two pathological defects may have a profound effect on brain function in the absence of any demonstrable brain lesion. It invites a reevaluation of normal head and neck venous anatomy. It should strike a cautionary note in the diagnosis of functional illness. It invites exploration of a remediable structural cause for Tourette syndrome.
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Affiliation(s)
| | - Stephen Kirker
- Department of Rehabilitation Medicine, Addenbrooke’s Hospital, Cambridge, United Kingdom
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4
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Schyns-van den Berg AM, Gupta A. Postdural puncture headache - revisited. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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Farnsworth PJ, Madhavan AA, Verdoorn JT, Shlapak DP, Johnson DR, Cutsforth-Gregory JK, Brinjikji W, Lehman VT. Spontaneous intracranial hypotension: updates from diagnosis to treatment. Neuroradiology 2023; 65:233-243. [PMID: 36336758 DOI: 10.1007/s00234-022-03079-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks, which result in continued loss of CSF volume and multiple debilitating clinical manifestations. The estimated annual incidence of SIH is 5/100,000. Diagnostic methods have evolved in recent years due to improved understanding of pathophysiology and implementation of advanced myelographic techniques. Here, we synthesize recent updates and contextualize them in an algorithm for diagnosis and treatment of SIH, highlighting basic principles and points of practice variability or continued debate. This discussion includes finer points of SIH diagnosis, CSF leak classification systems, less common types and variants of CSF leaks, brain MRI Bern scoring, potential SIH complications, key technical considerations, and positioning strategies for different types of dynamic myelography. The roles of conservative measures, non-targeted or targeted blood patches, surgery, and recently developed endovascular techniques are presented.
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Affiliation(s)
- Paul J Farnsworth
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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6
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Kumar R, Cutsforth-Gregory JK, Brinjikji W. Cerebrospinal Fluid Leaks, Spontaneous Intracranial Hypotension, and Chiari I Malformation. Neurosurg Clin N Am 2022; 34:185-192. [DOI: 10.1016/j.nec.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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7
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Roos C. Ipotensione intracranica spontanea. Neurologia 2022. [DOI: 10.1016/s1634-7072(21)45998-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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8
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Spontaneous intracranial hypotension: searching for the CSF leak. Lancet Neurol 2022; 21:369-380. [DOI: 10.1016/s1474-4422(21)00423-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
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Dobrocky T, Häni L, Rohner R, Branca M, Mordasini P, Pilgram-Pastor S, Kaesmacher J, Cianfoni A, Schär RT, Gralla J, Raabe A, Ulrich C, Beck J, Piechowiak EI. Brain Spontaneous Intracranial Hypotension Score for Treatment Monitoring After Surgical Closure of the Underlying Spinal Dural Leak. Clin Neuroradiol 2022; 32:231-238. [PMID: 35028683 DOI: 10.1007/s00062-021-01124-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is a debilitating condition requiring effective treatment; however, objective data on treatment response are scarce. PURPOSE To assess the suitability of the brain MRI-based SIH score (bSIH) for monitoring treatment success in SIH patients with a proven spinal cerebrospinal fluid (CSF) leak after microsurgical closure of the underlying dural breach. METHODS This retrospective cohort study included consecutive SIH patients with a proven spinal CSF leak, investigated at dedicated referral centre January 2012 to March 2020. The bSIH score integrates 6 imaging findings; 3 major (2 points) and 3 minor (1 point), and ranges from 0 to 9, with 0 indicating low and 9 high probability of spinal CSF loss. The score was calculated using brain magnetic resonance imaging (MRI) before and after surgical treatment of the underlying CSF leak. Headache intensity was registered on a numeric rating scale (NRS) (range 0-10). RESULTS In this study 52 SIH patients, 35 (67%) female, mean age 45.3 years, with a proven spinal CSF leak were included. The mean bSIH score decreased significantly from baseline to after surgical closure of the underlying dural breach (6.9 vs. 1.3, P < 0.001). A decrease in the NRS score was reported (8.6 vs. 1.2, P < 0.001). CONCLUSION The bSIH score is a simple tool which may serve to monitor treatment success in SIH patients after surgical closure of the underlying spinal dural leak. Its decrease after surgical closure of the underlying spinal dural breach indicates restoration of an equilibrium within the CSF compartment.
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Affiliation(s)
- Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland. .,Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany.
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Roman Rohner
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Mattia Branca
- Clinical Trial Unit, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Sara Pilgram-Pastor
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Alessandro Cianfoni
- Department of Neuroradiology, Neurocenter of Italian Switzerland, Lugano, Switzerland
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christian Ulrich
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital Bern, Freiburgstraße 8, 3010, Bern, Switzerland
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Cheng SJ, Hakkinen I, Zhang P, Roychowdhury S. Paradoxical headache in a case of chronic spontaneous intracranial hypotension and multiple perineural cysts. Headache 2021; 61:1291-1294. [PMID: 34510443 DOI: 10.1111/head.14188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Samantha J Cheng
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ian Hakkinen
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Pengfei Zhang
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sudipta Roychowdhury
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Angelopoulou E, Pantou E, Zacharis G, Rentzos M, Stefanis L, Zouvelou V. Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00109-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Spontaneous intracranial hypotension (SIH) is characterized by positional headache caused by low CSF pressure, without any major traumatic event. Optimal treatment is still debated; epidural blood patch (EBP) is usually used after unsuccessful conservative treatment with variable efficacy and potentially severe complications. Although steroids have been reported to be beneficial, their effectiveness is still controversial, and more clinical evidence is needed.
Case presentation
A 37-year-old woman was admitted to the neurology department due to severe orthostatic headache with nausea over the last 5 days. No trauma history or spinal manipulation were mentioned. On arrival, neurological examination, brain CT, and laboratory investigation were normal. Intracranial hypotension was clinically suspected, and lumbar puncture revealed low opening pressure. Brain MRI demonstrated pachymeningeal gadolinium enhancement and distended and rounded dural venous sinuses, while cervicothoracic spine MRI revealed thoracic CSF leakage, leading to SIH diagnosis. The patient was treated with high-dose intravenous methylprednisolone, with complete clinical resolution within 24 h.
Conclusions
Our case, combined with literature evidence, supports the high-dose intravenous corticosteroids as a reasonable treatment option in selected cases, before trying EBP or surgical repair. Randomized clinical trials are needed, in order to optimize SIH patients’ outcomes.
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Ahmed I, Majeed A, Fernando R, Hyare H, Columb M, Setty T. Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study. Eur J Anaesthesiol 2021; 38:777-784. [PMID: 33470687 DOI: 10.1097/eja.0000000000001445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Currently, performing an epidural blood patch (EBP) for postdural puncture headache (PDPH) remains a subjective clinical decision. An evidence-based protocol may be of value in identifying women at high risk of developing a severe PDPH. OBJECTIVE To investigate a potential correlation between the extent of CSF spread in the epidural space, as noted on Magnetic Resonance Imaging (MRI), and the likelihood of development of severe PDPH in obstetric patients. DESIGN A prospective double-blind quasi-observational study. SETTING Eight tertiary obstetric units, from NHS hospitals. PATIENTS Parturients with accidental dural puncture (ADP) underwent T1 and T2-weighted MRI scans of the brain and lumbar spine within 48 h after delivery. All women were followed up, daily, for 1 week. MAIN OUTCOME MEASURES For each woman, a PDPH severity score was calculated using a four-point Verbal Reporting Scale (none = 0, mild = 1, moderate = 2, severe = 3), with additional points awarded for visual, auditory and emetic symptoms. MRIs were reported by a neuroradiologist, blind to the patient details, using a predefined MRI score. RESULTS Twenty-two parturients were recruited; 86% (n=19) developed PDPH and 10 of these (53%) required an EBP. The median (range) time for the onset of PDPH was 24 (4 to 126) hours. The median (range) cumulative PDPH severity score was 10 (0 to 21), whereas, the median (range) MRI score was 2.5 (0 to 12). Spearman (rs) analysis identified a significant positive correlation (rs = 0.46; P = 0.024) between cumulative PDPH severity and MRI scores. Of all the radiological features identified in an MRI (lumbar dural shift, caudal brain displacement, epidural or intrathecal blood), the presence of intrathecal blood was most strongly correlated with PDPH severity (P = 0.043). CONCLUSION Following an ADP, the extent of CSF spread in the epidural space correlates with the severity of subsequent PDPH. CLINICAL TRIAL NUMBER AND REGISTRY URL ISRCTN14959004, https://www.isrctn.com/.
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Affiliation(s)
- Iftikhar Ahmed
- From the Department of Anaesthesia, King Faisal Specialist Hospital & Research Centre, Kingdom of Saudi Arabia (IA, AM), Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar (RF), Department of Anaesthesia, University College Hospital, London (HH, TS) and Department of Anaesthesia, University Hospital of South Manchester, Wythenshawe, UK (MC)
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13
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Chan TLH, Cowan R, Hindiyeh N, Hashmi S, Lanzman B, Carroll I. Spinal cerebrospinal fluid leak in the context of pars interarticularis fracture. BMC Neurol 2020; 20:162. [PMID: 32349710 PMCID: PMC7191704 DOI: 10.1186/s12883-020-01740-1] [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: 02/18/2020] [Accepted: 04/21/2020] [Indexed: 11/17/2022] Open
Abstract
Background Spinal cerebrospinal fluid (CSF) leak can lead to intracranial hypotension and is an important differential diagnosis to consider in patients with sudden-onset chronic daily headaches. Pars interarticularis (PI) fracture is a potential rare cause of suspected spinal CSF leak. Methods This is a retrospective case series of 6 patients with suspected spinal CSF leak evaluated between January 2016 and September 2019. All patients received a magnetic resonance imaging (MRI) of the brain with and without gadolinium, MRI whole spine and full spine computed tomography (CT) myelogram. Targeted epidural patches with fibrin sealant were performed. Treatment response at return visit (3 months post-patch) was documented. Results Six patients (4 females, 2 males) were diagnosed with a suspected spinal CSF leak and PI fracture. Mean age at the time of headache onset was 39 years old, and a range from 32 to 50 years old. Mean time to targeted epidural patches with fibrin sealant was 4.5 years. All 6 patients had PI fractures identified on CT myelogram and received targeted epidural patches with fibrin sealant at the site of the PI fracture. All patients had significant improvement in their headache intensity. Conclusion Our study highlights: 1) the importance of PI fracture as a possible culprit of suspected spinal CSF leak in patients with intracranial hypotension; 2) the added benefit of CT imaging for detecting bony abnormalities such as fractures in patients with intracranial hypotension; and 3) the successful treatment of suspected spinal CSF leak when targeting the fracture site.
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Abstract
PURPOSE OF REVIEW Spontaneous intracranial hypotension (SIH) is an underdiagnosed phenomenon predominantly presenting with low cerebrospinal fluid (CSF) pressure and postural headache in setting of CSF leak. The goal of this paper is to provide updates on the pathology, diagnosis, and management of SIH. The utility of multiple imaging modalities and the use of epidural blood patches and fibrin glue polymers are explored. RECENT FINDINGS In regard to diagnosis, new non-invasive modalities in detection of SIH including transorbital ultrasound and serum biomarkers are found. In addition, increased efficacy of large volume and repeated placement of multiple epidural blood patches (EBP) are seen. In addition, the management of refractory SIH using fibrin glue polymers has proved efficacious in recent case series. While the diagnosis may be challenging for clinicians, future research in SIH is leading to more rapid detection methods. Future studies may target optimal use of EBP in comparison to fibrin glue polymers, in addition to new developments in increased understanding of SIH physiology and phenotype.
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Montenegro MM, Cutsforth-Gregory JK. Orthostatic Headache After Suboccipital Craniectomy Without CSF Leak: Two Case Reports. Headache 2018; 58:1238-1243. [DOI: 10.1111/head.13346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/10/2018] [Accepted: 05/10/2018] [Indexed: 01/03/2023]
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Bordlee JW, Beakley BD, Mody R, McConville AP, Weed JT, McClure BP, Foldes PJ, Ma JG, Kaye AD, Eskander JP. A case of paradoxical presentation of a postural postdural puncture headache after combined spinal-epidural anesthesia. J Clin Anesth 2017; 38:156-157. [PMID: 28372658 DOI: 10.1016/j.jclinane.2016.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 08/09/2016] [Indexed: 10/20/2022]
Abstract
We report a case of paradoxical presentation of a postural postdural puncture headache secondary to dural puncture with a 25-gauge Whitacre needle for combined spinal-epidural anesthesia. This 27-year-old female patient presented to the emergency department with elevated blood pressure and a global headache 9 days after administration of epidural anesthesia for a spontaneous vaginal delivery after an uncomplicated pregnancy. The patient reported that the headache was more intense when lying down and immediately improved when she sat or stood up from a recumbent position. The patient was discharged from emergency department after an improvement following treatment with labetalol, ondansetron, ketorolac, and fluid resuscitation.
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Affiliation(s)
- John W Bordlee
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA.
| | - Burton D Beakley
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Rayomond Mody
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Anne P McConville
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Jonathan T Weed
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Brian P McClure
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Peter J Foldes
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Jonathan G Ma
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Alan D Kaye
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
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Lin JP, Zhang SD, He FF, Liu MJ, Ma XX. The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain 2017; 18:4. [PMID: 28091819 PMCID: PMC5236046 DOI: 10.1186/s10194-016-0708-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/07/2016] [Indexed: 01/03/2023] Open
Abstract
Intracranial hypotension, especially spontaneous intracranial hypotension (SIH), is a well-recognized entity associated with cerebrospinal fluid (CSF) leaks, and has being recognized better in resent years, while still woefully inadequate. An increasing number of factors including iatrogenic factors are realized to involve in development and progression of intracranial hypotension. The diagnosis remains difficult due to the various clinical manifestations, some of which are nonspecific and easily to be neglected. Multiple imaging tests are optional in CSF leakage identification while clinicians are still confronted with difficulties when making selection resulting from superiorities and disadvantages of different imaging tests. Treatments for intracranial hypotension are multifarious but evidence is anecdotal. Values of autologous epidural blood patching (EBP), the mainstay of first-line interventional treatment currently, is getting more and more regards while there are no systematic review of its efficacy and risks. Hereby, the purpose of this review was to reveal the present strategy of intracranial hypotension diagnosis and treatment by reviewing literatures, coupled with our experience in clinical work.
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Affiliation(s)
- Jin-Ping Lin
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Shu-Dong Zhang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Fei-Fang He
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China.
| | - Min-Jun Liu
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Xiao-Xu Ma
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
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Dash D, Jalali A, Harsh V, Omeis I. Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25 Suppl 1:209-15. [PMID: 26831535 DOI: 10.1007/s00586-016-4408-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported. METHODS Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed. RESULTS The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm. CONCLUSIONS Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.
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Affiliation(s)
- Debadutta Dash
- University Hospitals, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Ali Jalali
- Department of Neurosurgery, Baylor College of Medicine, 6501 Fannin St, Suite NC 100, Houston, TX, 77030, USA
| | - Viraat Harsh
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, JH, 834009, India
| | - Ibrahim Omeis
- Department of Neurosurgery, Baylor College of Medicine, 6501 Fannin St, Suite NC 100, Houston, TX, 77030, USA.
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Higgins N, Trivedi R, Greenwood R, Pickard J. Brain Slump Caused by Jugular Venous Stenoses Treated by Stenting: A Hypothesis to Link Spontaneous Intracranial Hypotension with Idiopathic Intracranial Hypertension. J Neurol Surg Rep 2015; 76:e188-93. [PMID: 26251803 PMCID: PMC4520985 DOI: 10.1055/s-0035-1555015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 04/29/2015] [Indexed: 01/03/2023] Open
Abstract
Spontaneous intracranial hypotension, of which brain slump is an extreme expression, is caused by a cerebrospinal fluid leak. The reason the leak develops in the first place, however, is unknown, and some cases can be very difficult to manage. We describe a patient with severe symptoms of spontaneous intracranial hypotension and brain slump documented by magnetic resonance imaging whose clinical syndrome and structural brain anomaly resolved completely after treatment directed exclusively at improving cranial venous outflow. Diagnostics included computed tomography (CT) venography, catheter venography, and jugular venoplasty. CT venography showed narrowing of both internal jugular veins below the skull base. Catheter venography confirmed that these were associated with pressure gradients. Jugular venoplasty performed on two separate occasions as a clinical test gave temporary respite. Lasting remission (2 years of follow-up) was achieved by stenting the dominant internal jugular vein. These findings and this outcome suggest a mechanism for the development of spontaneous intracranial hypotension that would link it to idiopathic intracranial hypertension and have cranial venous outflow obstruction as the underlying cause.
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Affiliation(s)
- Nicholas Higgins
- Department of Radiology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Rikin Trivedi
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Richard Greenwood
- National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - John Pickard
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
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Gottschalk A. [Cerebrospinal fluid leakage. Indications, technique and results of treatment with a blood patch]. Radiologe 2015; 55:471-8. [PMID: 26036932 DOI: 10.1007/s00117-014-2804-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND In most cases cerebrospinal fluid (CSF) leaks are iatrogenic and caused by medical interventions, such as lumbar puncture, peridural anesthesia and surgical interventions on the spine, However, spontaneous cerebral hypotension is currently detected more frequently due to improvements in diagnostic possibilities but often the cause cannot be clarified with certainty. METHODS There are various diagnostic tools for confirming the diagnosis and searching for the site of CSF leakage, such as postmyelography computed tomography (postmyelo-CT), indium(111) radioisotope cisternography and (myelo) magnetic resonance imaging (MRI), which show different sensitivities. In accordance with own experience native MRI with fat-saturated T2-weighted sequences is often sufficient for diagnosing CSF leakage and the site. For the remaining cases an additional postmyelo-CT or alternatively myelo-MRI is recommended. In some patients with spontaneous cranial hypotension multiple CSF leaks are found at different spinal levels. The main symptom in most cases is an orthostatic headache. While post-puncture syndrome is self-limiting in many cases, spontaneous CSF leakage usually requires blood patch therapy. A lumbar blood patch can be safely carried out under guidance by fluoroscopy. In the case of a cervical or dorsal blood patch, CT guidance is recommended, which ensures epidural application of the blood patch and minimizes the risk of damaging the spinal cord. Despite a high success rate at the first attempt with a blood patch of up to 85%, some cases require repeating the blood patch. A targeted blood patch of a CSF leak should generally be favoured over a blindly placed blood patch; nevertheless, if a CSF leak cannot be localized by CT or MRI a therapeutic attempt with a lumbar blood patch can be carried out. After a successful blood patch intracranial hygromas and pachymeningeal enhancement in the head show fast regression; however, epidural hygromas of the spine can persist for a period of several months, even though patients are already free of symptoms. CONCLUSION In total, blood patch therapy is a safe and technically relative simple method with a high success rate. Therefore, it represents the therapy of choice in patients with spontaneous cerebrospinal fluid leakage as well as in cases of post-lumbar puncture syndrome refractory to conservative therapy.
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Affiliation(s)
- A Gottschalk
- Abteilung Neuroradiologie, Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488, Frankfurt am Main, Deutschland,
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Ducros A, Biousse V. Headache arising from idiopathic changes in CSF pressure. Lancet Neurol 2015; 14:655-68. [DOI: 10.1016/s1474-4422(15)00015-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 12/24/2022]
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Roos C. Ipotensione intracranica spontanea. Neurologia 2015. [DOI: 10.1016/s1634-7072(14)69822-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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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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Mokri B. Spontaneous Low Pressure, Low CSF Volume Headaches: Spontaneous CSF Leaks. Headache 2013; 53:1034-53. [DOI: 10.1111/head.12149] [Citation(s) in RCA: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Bahram Mokri
- Department of Neurology; Mayo Clinic; Rochester; MN; USA
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Ahn JS, Akincioglu C, Gulka I, Coome G. Spontaneous low cerebrospinal fluid pressure headache: an emergency medicine perspective. CAN J EMERG MED 2013; 15:53-8. [DOI: 10.2310/8000.2012.120790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACT:Spontaneous low cerebrospinal fluid pressure headaches are a rare but treatable cause of debilitating headaches. The condition is characterized by a postural headache in the absence of any recent spinal procedures and is exacerbated when upright and relieved when supine. Diagnosis and treatment are often delayed, however, due to a lack of recognition and awareness, as illustrated by this case report of a patient who had multiple emergency department visits before further investigations were sought.
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Schievink WI, Chu RM, Maya MM, Johnson JP, Cohen HCM. Spinal manifestations of spontaneous intracranial hypotension. J Neurosurg Spine 2013; 18:96-101. [DOI: 10.3171/2012.10.spine12469] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Object
The goal of the study was to elucidate the spinal manifestations of spontaneous intracranial hypotension.
Methods
The authors reviewed the medical records and imaging studies of 338 consecutive patients with spontaneous intracranial hypotension who were evaluated at their institution between 2001 and 2010.
Results
Twenty patients (6%; mean age 35.8 [range 16 to 60 years]; 5 males and 15 females) had convincing signs or symptoms referable to the spinal cord or spinal nerve roots. The spinal manifestations consisted of radiculopathy in 11 patients (unilateral in 8 and bilateral in 3), myelopathy in 8 patients, and bibrachial amyotrophy in 1 patient. The cervical spine was involved in 12 patients, the thoracic spine in 5, and the lumbosacral spine in 3. The spinal symptoms were positional in only 3 patients. The spinal manifestations occurred around the time of the headache onset in 16 patients, and months to years after the positional headache had resolved in 4 patients. A large extrathecal CSF collection causing compression of the spinal cord or nerve root was responsible for the spinal manifestations in the majority of patients. Treatment of the spinal CSF leak resulted in resolution of the spinal manifestations along with the headache, except for those in the patient with bibrachial amyotrophy.
Conclusions
Spinal manifestations are uncommon in cases of spontaneous intracranial hypotension, occurring in about 6% of patients, but myelopathy and radiculopathy involving all spinal segments do occur. Unlike the headache, the spinal manifestations usually are not positional and are caused by mass effect from an extradural CSF collection.
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Loya JJ, Mindea SA, Yu H, Venkatasubramanian C, Chang SD, Burns TC. Intracranial hypotension producing reversible coma: a systematic review, including three new cases. J Neurosurg 2012; 117:615-28. [PMID: 22725982 DOI: 10.3171/2012.4.jns112030] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Intracranial hypotension is a disorder of CSF hypovolemia due to iatrogenic or spontaneous spinal CSF leakage. Rarely, positional headaches may progress to coma, with frequent misdiagnosis. The authors review reported cases of verified intracranial hypotension-associated coma, including 3 previously unpublished cases, totaling 29. Most patients presented with headache prior to neurological deterioration, with positional symptoms elicited in almost half. Eight patients had recently undergone a spinal procedure such as lumbar drainage. Diagnostic workup almost always began with a head CT scan. Subdural collections were present in 86%; however, intracranial hypotension was frequently unrecognized as the underlying cause. Twelve patients underwent one or more procedures to evacuate the collections, sometimes with transiently improved mental status. However, no patient experienced lasting neurological improvement after subdural fluid evacuation alone, and some deteriorated further. Intracranial hypotension was diagnosed in most patients via MRI studies, which were often obtained due to failure to improve after subdural hematoma (SDH) evacuation. Once the diagnosis of intracranial hypotension was made, placement of epidural blood patches was curative in 85% of patients. Twenty-seven patients (93%) experienced favorable outcomes after diagnosis and treatment; 1 patient died, and 1 patient had a morbid outcome secondary to duret hemorrhages. The literature review revealed that numerous additional patients with clinical histories consistent with intracranial hypotension but no radiological confirmation developed SDH following a spinal procedure. Several such patients experienced poor outcomes, and there were multiple deaths. To facilitate recognition of this treatable but potentially life-threatening condition, the authors propose criteria that should prompt intracranial hypotension workup in the comatose patient and present a stepwise management algorithm to guide the appropriate diagnosis and treatment of these patients.
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Affiliation(s)
- Joshua J Loya
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5487, USA
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Chan EK, Yan B, Ryan MM. Spontaneous intracranial hypotension in childhood: a case report and review of the literature. J Child Neurol 2011; 26:761-6. [PMID: 21343606 DOI: 10.1177/0883073810389042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Spontaneous intracranial hypotension results from 1 or more spontaneous spinal cerebrospinal fluid leaks, and generally presents with severe and persisting orthostatic headache. Diagnosis can be difficult as spontaneous intracranial hypotension is very rare in childhood and has a wide spectrum of clinical features and neuroimaging findings. Lumbar autologous epidural blood patch can be helpful for confirmation of diagnosis and symptom relief. We report a 15-year-old female with spontaneous intracranial hypotension who experienced immediate resolution of her symptoms following lumbar autologous epidural blood patch on 2 occasions, and review the literature on this well-recognized but probably underdiagnosed headache syndrome in childhood.
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Affiliation(s)
- Eunice K Chan
- Children's Neurosciences Centre, The Royal Children's Hospital Melbourne, Flemington Road, Parkville, Victoria, Australia
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Spontaneous intracranial hypotension. Headache 2010. [DOI: 10.1017/cbo9780511750472.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Diener HC, Johansson U, Dodick DW. Headache attributed to non-vascular intracranial disorder. HANDBOOK OF CLINICAL NEUROLOGY 2010; 97:547-587. [PMID: 20816456 DOI: 10.1016/s0072-9752(10)97050-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.
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Strupp M, Katsarava Z. Postpunktionelles und spontanes Liquorunterdrucksyndrom. DER NERVENARZT 2009; 80:1509-19. [DOI: 10.1007/s00115-009-2833-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Spontaneous intracranial hypotension is an uncommon but not rare cause of new onset daily persistent headaches. A delay in diagnosis is the norm. Women are affected more commonly than men and most are in the fifth or sixth decade of life. The underlying cause is a spontaneous spinal cerebrospinal fluid (CSF) leak. Typically the headache is orthostatic in nature but other headache patterns occur as well. Associated symptoms are common and include neck pain, a change in hearing, diplopia, facial numbness, cognitive abnormalities and even coma. Typical imaging findings consist of subdural fluid collections, pachymeningeal enhancement, pituitary hyperaemia and brain sagging, but magnetic resonance imaging may be normal. Myelography is the study of choice to identify the CSF leak but is not always necessary to make the diagnosis. Treatment consists of bedrest, abdominal binder, epidural blood patching, percutaneous fibrin glue injection or surgical CSF leak repair. Outcomes have been poorly studied.
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Affiliation(s)
- WI Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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35
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Liu H, Kaye AD, Comarda N, Li M. Paradoxical postural cerebrospinal fluid leak–induced headache: report of two cases. J Clin Anesth 2008; 20:383-385. [DOI: 10.1016/j.jclinane.2008.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2007] [Revised: 01/16/2008] [Accepted: 01/17/2008] [Indexed: 11/26/2022]
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Schievink WI, Maya MM, Louy C, Moser FG, Tourje J. Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol 2008; 29:853-6. [PMID: 18258706 DOI: 10.3174/ajnr.a0956] [Citation(s) in RCA: 180] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE Comprehensive diagnostic criteria encompassing the varied clinical and radiographic manifestations of spontaneous intracranial hypotension are not available. Therefore, we propose a new set of diagnostic criteria. MATERIALS AND METHODS The diagnostic criteria are based on results of brain and spine imaging, clinical manifestations, results of lumbar puncture, and response to epidural blood patching. The diagnostic criteria include criterion A, the demonstration of extrathecal CSF on spinal imaging. If criterion A is not met, criterion B, which is cranial MR imaging findings of spontaneous intracranial hypotension, follows, with at least one of the following: 1) low opening pressure, 2) spinal meningeal diverticulum, or 3) improvement of symptoms after epidural blood patch. If criteria A and B are not met, there is criterion C, the presence of all of the following or at least 2 of the following if typical orthostatic headaches are present: 1) low opening pressure, 2) spinal meningeal diverticulum, and 3) improvement of symptoms after epidural blood patch. These criteria were applied to a group of 107 consecutive patients evaluated for spontaneous spinal CSF leaks and intracranial hypotension. RESULTS The diagnosis was confirmed in 94 patients, with use of criterion A in 78 patients, criterion B in 11 patients, and criterion C in 5 patients. CONCLUSIONS A new diagnostic scheme is presented reflecting the wide spectrum of clinical and radiographic manifestations of spontaneous spinal CSF leaks and intracranial hypotension.
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Affiliation(s)
- W I Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Tsai PH, Fuh JL, Lirng JF, Wang SJ. Comparisons between heavily T2-weighted MR and CT myelography studies in two patients with spontaneous intracranial hypotension. Cephalalgia 2008; 28:653-7. [PMID: 18422723 DOI: 10.1111/j.1468-2982.2008.01562.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Our previous study demonstrated that heavily T2-weighted magnetic resonance (MR) myelography could successfully detect abnormal cerebrospinal fluid (CSF) collections in patients with spontaneous intracranial hypotension (SIH); however, its ability to demonstrate ongoing CSF leakage sites is uncertain. Currently, computed tomographic (CT) myelography is still considered the study of choice for such a purpose. In this study, we compared the results of the two imaging modalities in two patients with SIH. CSF leakages, such as C1-2 extraspinal collections, CSF along nerve root sleeves, and epidural fluid collections were noted on both studies with minor discrepancies. CSF collection along nerve root sleeves demonstrated by MR myelography was the most likely ongoing leakage site in comparison with CT myelography. Targeted epidural blood patches in both patients resulted in complete headache resolution. Non-invasive, non-contrasted and time-saving MR myelography is a promising study for patients with SIH. Further large-scale validation studies are needed.
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Affiliation(s)
- P-H Tsai
- Department of Neurology, Suao Veterans Hospital, Yi-Lan, Taiwan
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Cumarasingam B, Mansberg R, Mansberg V, Szeto E, Garrick R. Multimodality Imaging of a Spontaneous Cerebrospinal Fluid Leak. Clin Nucl Med 2007; 32:210-2. [PMID: 17314599 DOI: 10.1097/rlu.0b013e31803073e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Brenda Cumarasingam
- Department of Nuclear Medicine, St. Vincent's Hospital, Darlinghurst, Australia
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Moriyama E, Nishida A, Ishikawa S. Posttraumatic Migraine. J Neurosurg 2005; 103:934-5; author reply 935. [PMID: 16305002 DOI: 10.3171/jns.2005.103.5.0934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Evans RW, Boes CJ. Spontaneous Low Cerebrospinal Fluid Pressure Syndrome Can Mimic Primary Cough Headache. Headache 2005; 45:374-7. [PMID: 15836576 DOI: 10.1111/j.1526-4610.2005.05076.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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