Distribution Patterns of Spinal Epidural Fluid in Patients with Spontaneous Intracranial Hypotension Syndrome

A Case of Neck Pain in a Patient with Spontaneous Cerebrospinal Fluid Leak Who Showed Characteristic Findings on Cervical Spine MRI

We report a case of a patient with neck pain only who was diagnosed with spontaneous cerebrospinal fluid leak (SCFL) based on characteristic findings on cervical spine magnetic resonance imaging (MRI). The patient was a 47-year-old man who had been experiencing neck pain for 3 days. He experienced neck pain when he got up in the morning and could not keep standing. Cervical spine MRI showed significant dilatation of the anterolateral dural canal veins at the C2 level. Under the suspicion of SCFL, additional thoracic spine MRI was performed, which revealed epidural fluid collection in the lower thoracic spine. He underwent bed rest, but his symptoms returned. Epidural blood patch (EBP) was performed. The symptoms improved after EBP, and the venous dilatation disappeared on MRI. Venous dilatation in SCFL is considered an effect of epidural space enlargement due to dural sac shrinkage caused by cerebrospinal fluid loss. Therefore, venous dilatation in the cervical spine is an indirect finding of SCFL. It has been reported that images of epidural fluid collection and dural canal collapse on spinal MRI are useful as direct findings in the diagnosis of SCFL, and these findings are most noticeable at the thoracic level. Because SCFL with neck pain only also exists, dilated images of the epidural vein are valuable for diagnosing SCFL, and neurospine surgeons should be aware of this finding when encountering patients complaining of neck pain.

The SIH-EBP Score: A grading scale to predict the response to the first epidural blood patch in spontaneous intracranial hypotension

BACKGROUND

To develop and validate an easy-to-use scoring system to predict the response to the first epidural blood patching in patients with spontaneous intracranial hypotension.

METHODS

This study recruited consecutive patients with spontaneous intracranial hypotension receiving epidural blood patching in a tertiary medical center, which were chronologically divided into a derivation cohort and a validation cohort. In the derivation cohort, factors associated with the first epidural blood patching response were identified by using multivariable logistic regression modeling. A scoring system was developed, and the cutoff score was determined by using the receiver operating characteristic curve. The findings were verified in an independent validation cohort.

RESULTS

The study involved 280 patients in the derivation cohort and 78 patients in the validation cohort. The spontaneous intracranial hypotension-epidural blood patching score (range 0-5) included two clinical variables (sex and age) and two radiological variables (midbrain-pons angle and anterior epidural cerebrospinal fluid collections). A score of ≥3 was predictive of the first epidural blood patching response, which was consistent in the validation cohort. Overall, patients who scored ≥3 were more likely to respond to the first epidural blood patching (odds ratio = 10.3).

CONCLUSION

For patients with spontaneous intracranial hypotension-epidural blood patching score ≥3, it is prudent to attempt at least one targeted epidural blood patching before considering more invasive interventions.

Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center

BACKGROUND

 Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT).

OBJECTIVE

 To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward.

METHODS

 Review of the medical files of three patients and description of clinical and surgical outcomes.

RESULTS

 Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with laminoplasty. Both of them had uneventful recovery and remission in surgery follow-up.

CONCLUSION

 The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.

Imaging of intraspinal cystic lesions: A review

Several distinct conditions present as cystic or pseudocystic lesions within the spinal canal. Some of the most common spinal cystic lesions include spinal meningeal cysts, juxtafacet cysts, dermoid/epidermoid cysts, nerve sheath tumors, and syringohydromyelia. Clinical presentation is usually nonspecific and imaging characteristics are frequently overlapping, which may pose a challenging presurgical diagnosis. We provide a pictorial review of cystic intraspinal lesions and discuss the main imaging features that can aid the neuroradiologist in the differential diagnosis. First, we propose a categorization of the lesions according to their location as extradural, intradural extramedullary, and intramedullary. This is a crucial initial step in the diagnostic workup and surgical planning. Second, for each of these locations, we organize the lesions according to their etiology: congenital and developmental disorders, degenerative disorders, traumatic or postsurgical collections, infectious conditions, neoplastic lesions, and other miscellaneous disorders. Finally, we summarize the clinical highlights and MR features that provide important insights for the differential diagnosis. MR is the technique of choice in presurgical evaluation and postsurgery follow-up. It provides accurate lesion localization and characterization and, most of the times, it will allow a confident differential diagnosis. High-resolution three-dimensional T2-weighted sequences and diffusion-weighted imaging can provide important hints in specific cases. Signal correlation with T1-weighted and fat-saturated sequences allows to differentiate true cystic lesions from hemorrhage or fat tissue.

Spontaneous intracranial hypotension: the role of radiology in diagnosis and management

Spontaneous intracranial hypotension (SIH) is a condition that results from leakage of cerebrospinal fluid (CSF) from the spine, and which typically presents with debilitating orthostatic headache, but can be associated with a wide range of other symptoms. The causes of spontaneous CSF leaks that lead to SIH include dural tears, leaking meningeal diverticula, and CSF-venous fistulas. Imaging plays a central role in the initial diagnosis of SIH and in its subsequent investigation and management. This article reviews the typical neuroimaging manifestations of SIH and discusses the utility of different myelographic techniques for localising spinal CSF leaks as well as the role of image-guided treatment.

Dural sac shrinkage signs on magnetic resonance imaging at the thoracic level in spontaneous intracranial hypotension-its clinical significance

BACKGROUND

Spontaneous intracranial hypotension (SIH) is secondary to a cerebrospinal fluid leak at the spinal level without obvious causative events. Several signs on brain and cervical spine magnetic resonance (MR) imaging (MRI) have been associated with SIH but can be equivocal or negative. This retrospective study sought to identify characteristic SIH signs on thoracic spinal MRI.

METHODS

Cranial and spinal MR images of 27 consecutive patients with classic SIH symptoms, who eventually received epidural autologous blood patches (EBPs), were analyzed.

RESULTS

The most prevalent findings on T2-weighted MRI at the thoracic level were anterior shift of the spinal cord (96.3%) and dorsal dura mater (81.5%), probably caused by dural sac shrinkage. These dural sac shrinkage signs (DSSS) were frequently accompanied by cerebrospinal fluid collection in the posterior epidural space (77.8%) and a prominent epidural venous plexus (77.8%). These findings disappeared in all six patients who underwent post-EBP spinal MRI. Dural enhancement and brain sagging were minimum or absent on the cranial MR images of seven patients, although DSSS were obvious in these seven patients. For 23 patients with SIH and 28 healthy volunteers, a diagnostic test using thoracic MRI was performed by 13 experts to validate the usefulness of DSSS. The median sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy of the DSSS were high (range, 0.913-0.931).

CONCLUSIONS

Detection of DSSS on thoracic MRI facilitates an SIH diagnosis without the use of invasive imaging modalities. The DSSS were positive even in patients in whom classic cranial MRI signs for SIH were equivocal or minimal.

Intravenous enhanced 3D FLAIR imaging to identify CSF leaks in spontaneous intracranial hypotension: Comparison with MR myelography

Purpose

To evaluate the clinical utility of intravenous gadolinium-enhanced heavily T2-weighted 3D fluid-attenuated inversion recovery (HT2-FLAIR) imaging for identifying spinal cerebrospinal fluid (CSF) leaks in patients with spontaneous intracranial hypotension (SIH).

Methods

Patients with SIH underwent MR myelography and post-contrast HT2-FLAIR imaging after an intravenous gadolinium injection. Two types of CSF leaks (epidural fluid collection and CSF leaks around the nerve root sleeve) at each vertebral level were compared between the 2 sequences. The total numbers of CSF leaks and vertebral levels involved were recorded for the whole spine. The sequence that was superior for the overall visualization of epidural and paraspinal fluid collection was then selected.

Results

Nine patients with SIH were included in the present study. HT2-FLAIR imaging was equivalent or superior to MR myelography at each level for detecting the 2 types of CSF leaks. In the 2 types of CSF leaks, the total numbers of CSF leaks and levels involved were higher on HT2-FLAIR images than on MR myelography, while no significant difference was observed for CSF leaks around the nerve root sleeve. In all 9 patients, HT2-FLAIR imaging was superior to MR myelography for the overall visualization of epidural and paraspinal fluid collection.

Conclusion

Intravenous gadolinium-enhanced HT2-FLAIR imaging was superior to MR myelography for the visualization of CSF leaks in patients with SIH. This method can be useful for identifying spinal CSF leaks.