Expert Commentary: Role of Surgery for the Management of CSF Leaks

Clinical Findings, Radiological Characteristics, and Treatment Options of Spontaneous and Secondary Intracranial Hypotension: A Single-Center Experience in Turkey

Introduction  Intracranial hypotension can occur for many reasons, including trauma, surgery, congenital defects, or spontaneous rupture of the dura mater. Symptoms appear long before cerebrospinal fluid (CSF) leaks are diagnosed. Treatment procedures include a variety of conservative and invasive techniques appropriate to the nature of the etiological cause and the severity of the disease. In this cross-sectional study, we aimed to investigate the clinical and imaging features and treatment options of intracranial hypotension patients and to compare them in terms of different etiologies. Methods The data from intracranial hypotension patients were analyzed retrospectively. Symptomatology, neurological findings, and radiological features were compared between patients with spontaneous intracranial hypotension (SIH) and those with secondary causes. Radiological outcomes of conservative treatment and epidural blood patch (EBP) were also evaluated for both groups. Results Of the 30 patients, 23 were female. In 14 of the patients (46.6%), a possible cause of CSF leakage was detected. Compared to intracranial hypotension patients with a secondary cause, SIH patients complained of posterior neck and shoulder pain more frequently (p=0.014, p=0.006). MRI features did not differ significantly when the two groups were compared (p>0.05). The first and sixth-month follow-up MRIs of patients treated with EBP or a conservative approach showed similar improvement rates (p=0.788). Conclusions There was no significant difference in radiological recovery time between conservative treatment and EBP in patients with intracranial hypotension. Radiological recovery times are similar in patients with secondary intracranial hypotension and SIH.

Spontaneous intracranial hypotension: updates from diagnosis to treatment

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.

Diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension: a systematic review and meta-analysis

OBJECTIVES

To investigate the pooled diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension (SIH).

METHODS

A literature search of the MEDLINE/PubMed and Embase databases was conducted until July 25, 2021, including studies with the following inclusion criteria: (a) population: patients with newly diagnosed SIH; (b) diagnostic modality: MR myelography or MR myelography with intrathecal gadolinium for evaluation of CSF leakage; (c) outcomes: diagnostic yield of MR myelography or MR myelography with intrathecal gadolinium. The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects modeling was used to calculate the pooled estimates. Subgroup analysis regarding epidural fluid collection and meta-regression were additionally performed.

RESULTS

Fifteen studies with 643 patients were included. Eight studies used MR myelography with intrathecal gadolinium, and 11 used MR myelography. The overall quality of the included studies was moderate. The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) and that of MR myelography with intrathecal gadolinium was 83% (95% CI, 51-96%). There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium (p = 0.512). In subgroup analysis, the pooled diagnostic yield of the epidural fluid collection was 91% (95% CI, 84-94%). In meta-regression, the diagnostic yield was unaffected regardless of consecutive enrollment, magnet strength, or 2D/3D.

CONCLUSIONS

MR myelography had a high diagnostic yield in patients with SIH. MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.

KEY POINTS

• The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) in patients with spontaneous intracranial hypotension. • There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium. • MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.

[Spinal CSF-venous fistula: case report and literature review]

Syndrome of spontaneous intracranial hypotension is increasingly described in the literature as a multifactorial disease with impairment of the quality of life and risk of mortality. CSF-venous fistula as a cause of intracranial hypotension syndrome is extremely rare and requires complex diagnosis and timely surgical treatment.

OBJECTIVE

We present a 55-year-old patient with acute spontaneous intracranial hypotension and spinal CSF-venous fistula. Literature data are also analyzed.

RESULTS

Algorithm for diagnosis and efficacy of microsurgical resection of CSF-venous fistula is demonstrated.

CONCLUSION

Intracranial hypotension following spinal fistula requires careful examination. Accurate understanding of pathophysiological and anatomical features of this disease is necessary to select an effective treatment method.

Spontaneous Intracranial Hypotension: Recommendations for Management

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.

Use of flat panel DynaCT myelography to locate the site of CSF leak

Spontaneous intracranial hypotension is often treated conservatively or with epidural blood patch. Patients who are resistant to these treatments require accurate imaging localisation of the site of cerebrospinal fluid (CSF) leak for surgical repair. We describe two patients where MRI, CT myelography and MRI gadolinium myelography showed evidence of a large volume of epidural CSF, but failed to identify the pressure site of leak. Subsequently, DynaCT (Siemens, Erlangen, Germany) accurately identified the site with confidence in both cases, confirmed at surgery. This technique of using a flat panel detector-based, angiographic system to produce high quality, high-contrast multiplanar CT images for detecting the source of rapid CSF leak is detailed.

[Post-dural puncture headache and blood-patch: theoretical and practical approach]

OBJECTIVE

To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH).

DATA SOURCES

Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache".

STUDY SELECTION

Six hundred and eighty-two pertinent studies were included and 200 were analysed.

DATA SYNTHESIS

Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the "gold standard" in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.

Transforaminal blood patch for the treatment of chronic headache from intracranial hypotension: a case report and review

This case report describes the successful treatment of chronic headache from intracranial hypotension with bilateral transforaminal (TF) lumbar epidural blood patches (EBPs). The patient is a 65-year-old male with chronic postural headaches. He had not had a headache-free day in more than 13 years. Conservative treatment and several interlaminar epidural blood patches were previously unsuccessful. A transforaminal EBP was performed under fluoroscopic guidance. Resolution of the headache occurred within 5 minutes of the procedure. After three months without a headache the patient had a return of the postural headache. A second transforaminal EBP was performed again with almost immediate resolution. The patient remains headache-free almost six months from the time of first TF blood patch. This is the first published report of the use of transforaminal epidural blood patches for the successful treatment of a headache lasting longer than 3 months.