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Yuzkan S, Benlice T, Guzelbey T, Yilmaz MF, Ozbey O, Sam Ozdemir M, Balsak S, Ozkiziltan U, Altunkaynak Y, Kilickesmez O, Kocak B. Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening. Neuroradiology 2024; 66:1335-1344. [PMID: 38658472 DOI: 10.1007/s00234-024-03359-2] [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] [Received: 01/03/2024] [Accepted: 04/13/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility. METHODS In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen's kappa statistics, interobserver agreement was assessed. RESULTS In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39). CONCLUSION The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.
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Affiliation(s)
- Sabahattin Yuzkan
- Department of Radiology, Koc University Hospital, Zeytinburnu, 34010, Istanbul, Turkey
| | - Tahsin Benlice
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Tevfik Guzelbey
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Mehmed Fatih Yilmaz
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Oner Ozbey
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Merve Sam Ozdemir
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Serdar Balsak
- Department of Radiology, Bezmialem Vakif University Hospital, Istanbul, Turkey
| | - Uluc Ozkiziltan
- Department of Radiology, Ege University School of Medicine, Izmir, Turkey
| | - Yavuz Altunkaynak
- Department of Neurology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Ozgur Kilickesmez
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey
| | - Burak Kocak
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, 34480, Istanbul, Turkey.
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Nethala P, GH S, Shivaram S. Superficial Cerebellar Siderosis and Spontaneous Intracranial Hypotension Secondary to Dural Tear. Neurohospitalist 2023; 13:445-446. [PMID: 37701255 PMCID: PMC10494827 DOI: 10.1177/19418744231179346] [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: 09/14/2023] Open
Abstract
Spinal dural tears are being increasingly recongnized to cause superficial siderosis and intracranial hypotension. We report a patient with chronic headache who was detected to have cerebellar superficial siderosis and subtle signs of intracranial hypotension on imaging. Spinal imaging showed an upper thoracic dural tear secondary to a paradiscal osteophyte. She improved significantly with surgical repair of the tear. We highlight the importance of recognizing superficial sideorsis in patients with chronic headache as it serves as a marker for dural tear and intracranial hypotension.
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Affiliation(s)
- Priscilla Nethala
- Department of General Medicine, Bangalore Baptist Hospital, Bangalore, India
| | - Sandhya GH
- Department of Radiology, Bangalore Baptist Hospital, Bangalore, India
| | - Sumanth Shivaram
- Department of Neurology, Bangalore Baptist Hospital, Bangalore, India
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Pinto MJ, Braz L, Fonseca J, Pereira P, Trigo Barbosa P, Gomes A, Guimarães J. [Guidelines for the Diagnosis and Treatment of Spontaneous Intracranial Hypotension]. ACTA MEDICA PORT 2023; 36:363-367. [PMID: 37130571 DOI: 10.20344/amp.19432] [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: 12/07/2022] [Accepted: 02/23/2023] [Indexed: 05/04/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is a syndrome characterized by disabling orthostatic headache, due to reduced cerebrospinal fluid (CSF) volume probably caused by a CSF fistula. It affects mostly women of working-age, although it is probably underdiagnosed. The aim of this article is to present a practical approach to the diagnosis and treatment of SIH. After a description of its symptoms and signs, we present a step-by-step approach to the confirmation of the diagnosis and treatment, considering different clinical scenarios. This is intended to guide clinical decision making, through a systematized and individualized management, aimed at the best interest of the patient.
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Affiliation(s)
- Maria João Pinto
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Luís Braz
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - José Fonseca
- Serviço de Neurorradiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Paulo Pereira
- Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto; Serviço de Neurocirurgia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Paula Trigo Barbosa
- Unidade de Dor Crónica. Serviço de Anestesiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Armanda Gomes
- Unidade de Dor Crónica. Serviço de Anestesiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Joana Guimarães
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
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Lin PT, Chen SP, Wang SJ. Update on primary headache associated with sexual activity and primary thunderclap headache. Cephalalgia 2023; 43:3331024221148657. [PMID: 36786380 DOI: 10.1177/03331024221148657] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND This narrative review aims to provide an update on primary headache associated with sexual activity and primary thunderclap headache. METHODS We conducted a literature search on PubMed with the keywords "headache associated with sexual activity", "sexual headache", "orgasmic cephalalgia", and "coital cephalalgia" in addition to "thunderclap headache" to assess the appropriateness of all published articles in this review. RESULTS Primary headache associated with sexual activity is a "primary" headache precipitated by sexual activity, which occurs as sexual excitement increases (progressive at onset), or manifests as an abrupt and intense headache upon orgasm (thunderclap at onset) or combines these above two features. Primary headache associated with sexual activity is diagnosed after a thorough investigation, including appropriate neuroimaging studies, to exclude life-threatening secondary causes such as subarachnoid hemorrhage. According to the criteria of the third edition of the International Classification of Headache Disorders, primary thunderclap headache is also a diagnosis by exclusion. The pathophysiology of primary headache associated with sexual activity and primary thunderclap headache remains incompletely understood. Treatment may not be necessary for all patients since some patients with primary headache associated with sexual activity and primary thunderclap headache have a self-limiting course. CONCLUSION A comprehensive neuroimaging study is needed for distinguishing primary headache associated with sexual activity or primary thunderclap headache from secondary causes. Primary headache associated with sexual activity and primary thunderclap headache are self-limited diseases and the prognoses are good, but some patients with primary headache associated with sexual activity may have a prolonged course.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Masourou Z, Papagiannakis N, Mantzikopoulos G, Mitsikostas DD, Theodoraki K. Treating Spontaneous Intracranial Hypotension with an Anesthetic Modality: The Role of the Epidural Blood Patch. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081109. [PMID: 35892911 PMCID: PMC9331680 DOI: 10.3390/life12081109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic and therapeutic challenge; it can present with a broad clinical spectrum of symptoms, can lead to SDH and, if conservative treatment fails, an epidural blood patch (EBP) is a viable treatment option. Although the exact etiology of SIH is not known, it is believed to be due to cerebrospinal fluid (CSF) leak or a low CSF pressure. Case Series: Three patients (two males and one female) with ages ranging between 38 and 53 years old who presented with complaints of not only an orthostatic headache, but also a variety of symptoms of SIH, including the formation of two SDHs in one of them, were included in this series. These patients did not respond to conservative management and, subsequently, given the clinical and radiological evidence of SIH, were referred to the Anesthesiology Department for an EBP. Diagnostic workup was facilitated by imaging modalities, including magnetic resonance imaging (MRI) of the brain and spinal cord, prior to the EBP. All three patients were subjected to an EBP with an 18-gauge epidural needle. A total of between 30 and 43 mL of autologous blood was collected from the patients and was injected into the epidural space under strict aseptic conditions. Two lumbar (L1-L2, L2-L3) EBPs and one thoracic (T11-T12) EBP were performed on the three patients, respectively. All patients reported complete resolution of symptoms following the EBPs, while MRI improved substantially. Conclusions: This report describes three cases of SIH with CSF leak originating from the cervical, the thoracic and the lumbar level. The EBP restored CSF pressure and relieved the patients' persistent symptoms. MRI helps in revealing indirect signs of a low volume of CSF, though it may not be possible to locate the actual site of the leak. In conclusion, EBP is a well-accepted and beneficial treatment modality for SIH when conventional measures fail.
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Affiliation(s)
- Zoi Masourou
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Nikolaos Papagiannakis
- Department of Neurology, Aiginiteion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (N.P.); (D.-D.M.)
| | | | - Dimos-Dimitrios Mitsikostas
- Department of Neurology, Aiginiteion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (N.P.); (D.-D.M.)
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Correspondence:
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Hsu CM, Liu YC, Chen YC, Fuh JL, Huang HC, Wang YF, Chiang IY, Wen YR. Efficacy and safety of cervicothoracic epidural blood patch for patients with spontaneous intracranial hypotension. Pain Pract 2022; 22:586-591. [PMID: 35585760 DOI: 10.1111/papr.13126] [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: 02/05/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Epidural blood patch (EBP) is a generally effective treatment for spontaneous intracranial hypotension (SIH) caused by cerebrospinal fluid (CSF) leakage through the spinal dura mater. It is still unclear, however, whether application near the leakage site (targeted EBP) is more effective than distal application (untargeted EBP). Further, EBP targeted to high thoracic or cervical spine levels is infrequent due to greater technical requirements and potential complications. Here we examined the safety and efficacy of EBP applied to high thoracic or cervical spine levels. METHODS We retrospectively reviewed the clinical and outcome data of 13 patients receiving cervical or high thoracic EBP for SIH. All patients were referred by neurologists following poor response to conservative treatment and presented with persistent headache aggravated by orthostatic changes. RESULTS Neuroimaging confirmed CSF leakage, and targeted EBP resulted in immediate pain improvement. Repeated injections provided additional improvement for patients with recurrent headache. No serious adverse events were documented during follow-up. CONCLUSION Based on recent studies and our clinical experience, we conclude that EBP targeted to the high thoracic and cervical spine is safe and effective for early-stage SIH.
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Affiliation(s)
- Chieh-Min Hsu
- Pain Management and Research Center, Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Cheng Liu
- Pain Management and Research Center, Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
| | - Ying-Chu Chen
- Department of Neurology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Jong-Ling Fuh
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Hui-Chun Huang
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Yen-Feng Wang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - I-Ying Chiang
- Pain Management and Research Center, Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
| | - Yeong-Ray Wen
- Pain Management and Research Center, Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan.,Department of Anesthesiology, School of Medicine, China Medical University, Taichung, Taiwan.,Center for Regional Anesthesia and Pain Medicine (CRAPM) of Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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