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Hashimoto M, Egawa S, Hirai T, Hashimoto J, Morishita S, Yamada K, Matsukura Y, Kaho R, Hada H, Oyama J, Yoshii T. Detection of Dural Defect Localization Using 4-Dimensional Dynamic Computed Tomography Myelography for Patients with Superficial Siderosis. World Neurosurg 2024; 187:e798-e806. [PMID: 38705268 DOI: 10.1016/j.wneu.2024.04.167] [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: 01/16/2024] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND There are cases of superficial siderosis (SS) with spinal ventral fluid-filled collection in the spinal canal. In our previous study, the balanced steady-state free precession sequence magnetic resonance imaging is useful in identifying the location of dural defects. However, because of its narrow scan area and long scan time, it cannot easily detect the defect location in some patients with small dural defect. In this study, we applied 4-dimensional (4D) dynamic computed tomography (CT) imaging, including time-axis imaging, to myelography using the latest CT imaging equipment, which can perform short-time continuous imaging, to identify the dural defect site. METHODS Twenty SS patients with ventral fluid-filled collection in the spinal canal (9 males, 11 females; mean age 61.6 years) underwent 4D dynamic CT myelography. A 192-row helical CT (SOMATOM Force, SIEMENS, Munich, Germany) with high-speed scanning capability was used to obtain 9-11 scans per minute at low dose while passing contrast medium into the subarachnoid space. Then, contrast leakage sites were identified. RESULTS The contrast leakage sites could be identified in all 20 cases: C7/Th1, 2 cases; Th1/2, 5 cases; Th2/3, 9 cases; Th3/4, 1 case; Th5/6, 1 case; Th7/8, 1 case; and Th8/9, 1 case. Eighteen cases underwent surgical operation, and actual dural defects were confirmed at the contrast leakage sites. The mean ± standard deviation of leakage time from contrast agent injection was 19.0 ± 9.2 s. CONCLUSIONS The 4D dynamic CT myelography can be used to reliably identify the location of spinal fluid leakage. In SS cases, dural defects could be visualized in an average of 19 seconds.
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Affiliation(s)
- Motonori Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoru Egawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Hirai
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shingo Morishita
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kentaro Yamada
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yu Matsukura
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryosuke Kaho
- Department of Radiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroto Hada
- Department of Radiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Jun Oyama
- Department of Radiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan.
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Zappi K, Giantini-Larsen A, Yan J, Konate M, Garton ALA, Knopman J, Stieg PE, Salama G, Park JK. Innovations in the Treatment of Spinal Cerebrospinal Fluid Leaks. World Neurosurg 2024; 187:304-312. [PMID: 38970201 DOI: 10.1016/j.wneu.2024.03.112] [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: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 07/08/2024]
Abstract
Spontaneous spinal cerebrospinal fluid (CSF) leaks are uncommon but can be neurologically debilitating. When initial treatments fail, definitive repair or closure of the leak is indicated. Depending upon the type of leak present, innovative strategies for their treatment have been developed. Among them are open surgical techniques using a transdural approach for the closure of ventral CSF leaks, minimally invasive tubular techniques for the reduction and repair of lateral meningeal diverticula, and endovascular embolization of CSF-venous fistulas. Illustrative cases demonstrating the indications for and implementation of these techniques are provided.
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Affiliation(s)
- Kyle Zappi
- Weill Cornell Medical College, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Jenny Yan
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Mawa Konate
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Andrew L A Garton
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Jared Knopman
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Philip E Stieg
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Gayle Salama
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - John K Park
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA; Department of Neurological Surgery, NewYork-Presbyterian Queens Hospital, Queens, New York, USA.
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3
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Sung J, Lin M, Giantini-Larsen A, Kim A, Edasery D, Roytman M, Strauss S, Schweitzer AD, Park JK, Salama G. Cerebrospinal Fluid Leaks: Challenges in Localizing Spontaneous Spinal Leak Sites and Minimally Invasive Treatment. World Neurosurg 2024; 187:294-303. [PMID: 38970200 DOI: 10.1016/j.wneu.2024.03.114] [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: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 07/08/2024]
Abstract
The confirmation of cerebrospinal fluid (CSF) leaks in the setting of spontaneous intracranial hypotension (SIH) by imaging involves a growing toolset of multimodal advanced spinal and skull base imaging techniques, for which exists a unique set of challenges for each CSF leak type. Furthermore, the repertoire of minimally invasive CSF leak treatment beyond nontargeted epidural blood patch administration has grown widely, with varied practices across institutions. This review describes current diagnostic imaging and treatment modalities as they apply to the challenges of CSF leak localization and management.
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Affiliation(s)
- Jeffrey Sung
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Matthew Lin
- Weill Cornell Medical College, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Andrew Kim
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - David Edasery
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Michelle Roytman
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Sara Strauss
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Andrew D Schweitzer
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - John K Park
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA; Department of Neurological Surgery, NewYork-Presbyterian Queens Hospital, Queens, New York, USA
| | - Gayle Salama
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA.
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4
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Wu JW, Wang SJ. Spontaneous Intracranial Hypotension: Clinical Presentation, Diagnosis, and Treatment Strategies. Neurol Clin 2024; 42:473-486. [PMID: 38575260 DOI: 10.1016/j.ncl.2024.02.002] [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: 04/06/2024]
Abstract
Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks. New evidence indicates that a lumbar puncture may not be essential for diagnosing every patient with SIH. Spinal neuroimaging protocols used for diagnosing and localizing spinal cerebrospinal fluid leaks include brain/spinal MRI, computed tomography myelography, digital subtraction myelography, and radionuclide cisternography. Complications of SIH include subdural hematoma, cerebral venous thrombosis, and superficial siderosis. Treatment options encompass conservative management, epidural blood patches, and surgical interventions. The early application of epidural blood patches in all patients with SIH is suggested.
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Affiliation(s)
- Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; Center for Quality Management, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan.
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Shah GV. Editorial Comment: Increasing Sensitivity in Detection of CSF-Venous Fistulas in Patients With Spontaneous Intracranial Hypotension. AJR Am J Roentgenol 2024; 222:e2431004. [PMID: 38380855 DOI: 10.2214/ajr.24.31004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
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Rohatgi VK, Robbins MS, Schievink WI, Chazen JL. Spontaneous absorption of osteophytic calcification associated with chronic dural tear and ventral spinal CSF leak. Neuroradiol J 2024; 37:257-260. [PMID: 37387398 PMCID: PMC10973820 DOI: 10.1177/19714009231187360] [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: 07/01/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) is associated with cerebrospinal fluid (CSF) hypovolemia, often from a traumatic dural tear from a calcified spinal osteophyte. Visualizing osteophytes on CT imaging can guide decision making on candidate leak sites. We report the atypical case of a 41-year-old woman whose ventral CSF leak was associated with an osteophyte that resorbed over an 18-month period. Full workup and treatment were delayed due to unexpected pregnancy and completion of gestational cycle with delivery of a healthy term infant. The patient initially presented with persistent orthostatic headaches with nausea and blurred vision. Initial MRI suggested brain sagging among other findings consistent with SIH. CT myelogram showed an extensive thoracic CSF leak with a prominent ventral T11-T12 osteophyte and multiple small disc herniations. The patient did not respond to epidural blood patches and deferred additional imaging due to her pregnancy. CT myelography performed 5 months post-partum showed an absence of the osteophyte; a follow-up digital subtraction myelogram performed 10 months post-partum showed evidence of source leak at T11-T12 level. T11-T12 laminectomy visualized and repaired a 5 mm ventral dural defect with symptom resolution. This report highlights the potential for a resorbed osteophyte to be the causative agent for long-standing dural tears that do not show visible calcifications on myelography.
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Affiliation(s)
- Varun K Rohatgi
- Department of Radiology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Matthew S Robbins
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Wouter I Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - J Levi Chazen
- Department of Radiology, Hospital of Special Surgery, New York, NY, USA
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Manjila S, Alsalama AA, Medani K, Patel S, Prabhune A, Ramachandran SN, Mani S. Is foramen magnum decompression for acquired Chiari I malformation like putting a finger in the dyke? - A simplistic overview of artificial intelligence in assessing critical upstream and downstream etiologies. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:153-165. [PMID: 38957754 PMCID: PMC11216646 DOI: 10.4103/jcvjs.jcvjs_160_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/09/2024] [Indexed: 07/04/2024] Open
Abstract
Background Missed diagnosis of evolving or coexisting idiopathic (IIH) and spontaneous intracranial hypotension (SIH) is often the reason for persistent or worsening symptoms after foramen magnum decompression for Chiari malformation (CM) I. We explore the role of artificial intelligence (AI)/convolutional neural networks (CNN) in Chiari I malformation in a combinatorial role for the first time in literature, exploring both upstream and downstream magnetic resonance findings as initial screening profilers in CM-1. We have also put together a review of all existing subtypes of CM and discuss the role of upright (gravity-aided) magnetic resonance imaging (MRI) in evaluating equivocal tonsillar descent on a lying-down MRI. We have formulated a workflow algorithm MaChiP 1.0 (Manjila Chiari Protocol 1.0) using upstream and downstream profilers, that cause de novo or worsening Chiari I malformation, which we plan to implement using AI. Materials and Methods The PRISMA guidelines were used for "CM and machine learning and CNN" on PubMed database articles, and four articles specific to the topic were encountered. The radiologic criteria for IIH and SIH were applied from neurosurgical literature, and they were applied between primary and secondary (acquired) Chiari I malformations. An upstream etiology such as IIH or SIH and an isolated downstream etiology in the spine were characterized using the existing body of literature. We propose the utility of using four selected criteria for IIH and SIH each, over MRI T2 images of the brain and spine, predominantly sagittal sequences in upstream etiology in the brain and multiplanar MRI in spinal lesions. Results Using MaChiP 1.0 (patent/ copyright pending) concepts, we have proposed the upstream and downstream profilers implicated in progressive Chiari I malformation. The upstream profilers included findings of brain sagging, slope of the third ventricular floor, pontomesencephalic angle, mamillopontine distance, lateral ventricular angle, internal cerebral vein-vein of Galen angle, and displacement of iter, clivus length, tonsillar descent, etc., suggestive of SIH. The IIH features noted in upstream pathologies were posterior flattening of globe of the eye, partial empty sella, optic nerve sheath distortion, and optic nerve tortuosity in MRI. The downstream etiologies involved spinal cerebrospinal fluid (CSF) leak from dural tear, meningeal diverticula, CSF-venous fistulae, etc. Conclusion AI would help offer predictive analysis along the spectrum of upstream and downstream etiologies, ensuring safety and efficacy in treating secondary (acquired) Chiari I malformation, especially with coexisting IIH and SIH. The MaChiP 1.0 algorithm can help document worsening of a previously diagnosed CM-1 and find the exact etiology of a secondary CM-I. However, the role of posterior fossa morphometry and cine-flow MRI data for intracranial CSF flow dynamics, along with advanced spinal CSF studies using dynamic myelo-CT scanning in the formation of secondary CM-I is still being evaluated.
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Affiliation(s)
- Sunil Manjila
- Department of Neurosurgery, Insight Institute of Neurosurgery and Neuroscience, Flint, MI, USA
| | | | - Khalid Medani
- Department of Occupational Medicine, Kaiser Permanente, Los Angeles, CA
| | - Shlok Patel
- Department of Orthopedic Surgery, BJ Medical College, Ahmedabad, Gujarat, India
| | - Anagha Prabhune
- Department of Neurosurgery, Sahyadri Medical Center, Pune, Maharashtra, India
| | | | - Sudhan Mani
- Department of Neurosurgery, Insight Institute of Neurosurgery and Neuroscience, Flint, MI, USA
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Schwartz FR, Kranz PG, Malinzak MD, Cox DN, Ria F, McCabe C, Harrawood B, Leithe LG, Samei E, Amrhein TJ. Myelography Using Energy-Integrating Detector CT Versus Photon-Counting Detector CT for Detection of CSF-Venous Fistulas in Patients With Spontaneous Intracranial Hypotension. AJR Am J Roentgenol 2024; 222:e2330673. [PMID: 38294163 DOI: 10.2214/ajr.23.30673] [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: 02/01/2024]
Abstract
BACKGROUND. CSF-venous fistulas (CVFs), which are an increasingly recognized cause of spontaneous intracranial hypotension (SIH), are often diminutive in size and exceedingly difficult to detect by conventional imaging. OBJECTIVE. This purpose of this study was to compare energy-integrating detector (EID) CT myelography and photon-counting detector (PCD) CT myelography in terms of image quality and diagnostic performance for detecting CVFs in patients with SIH. METHODS. This retrospective study included 38 patients (15 men and 23 women; mean age, 55 ± 10 [SD] years) with SIH who underwent both clinically indicated EID CT myelography (slice thickness, 0.625 mm) and PCD CT myelography (slice thickness, 0.2 mm; performed in ultrahigh-resolution mode) to assess for CSF leak. Three blinded radiologists reviewed examinations in random order, assessing image noise, discernibility of spinal nerve root sleeves, and overall image quality (each assessed using a scale of 0-100, with 100 denoting highest quality) and recording locations of the CVFs. Definite CVFs were defined as CVFs described in CT myelography reports using unequivocal language and having an attenuation value greater than 70 HU. RESULTS. For all readers, PCD CT myelography, in comparison with EID CT myelography, showed higher mean image noise (reader 1: 69.9 ± 18.5 [SD] vs 37.6 ± 15.2; reader 2: 59.5 ± 8.7 vs 49.3 ± 12.7; and reader 3: 57.6 ± 13.2 vs 42.1 ± 16.6), higher mean nerve root sleeve discernibility (reader 1: 81.6 ± 21.7 [SD] vs 30.4 ± 13.6; reader 2: 83.6 ± 10 vs 70.1 ± 18.9; and reader 3: 59.6 ± 13.5 vs 50.5 ± 14.4), and higher mean overall image quality (reader 1: 83.2 ± 20.0 [SD] vs 38.1 ± 13.5; reader 2: 80.1 ± 10.1 vs 72.4 ± 19.8; and reader 3: 57.8 ± 11.2 vs 51.9 ± 13.6) (all p < .05). Eleven patients had a definite CVF. Sensitivity and specificity of EID CT myelography and PCD CT myelography for the detection of definite CVF were 45% and 96% versus 64% and 85%, respectively, for reader 1; 36% and 100% versus 55% and 96%, respectively, for reader 2; and 57% and 100% versus 55% and 93%, respectively, for reader 3. The sensitivity was significantly higher for PCD CT myelography than for EID CT myelography for reader 1 and reader 2 (both p < .05) and was not significantly different between the two techniques for reader 3 (p = .45); for all three readers, specificity was not significantly different between the two modalities (all p > .05). CONCLUSION. In comparison with EID CT myelography, PCD CT myelography yielded significantly improved image quality with significantly higher sensitivity for CVFs (for two of three readers), without significant loss of specificity. CLINICAL IMPACT. The findings support a potential role for PCD CT myelography in facilitating earlier diagnosis and targeted treatment of SIH, avoiding high morbidity during potentially prolonged diagnostic workups.
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Affiliation(s)
- Fides R Schwartz
- Department of Radiology, Duke University Health System, Durham, NC
| | - Peter G Kranz
- Department of Radiology, Duke University Health System, Durham, NC
| | | | - David N Cox
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Francesco Ria
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Cindy McCabe
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Brian Harrawood
- Department of Radiology, Ravin Advanced Imaging Laboratories, Duke University Health System, Durham, NC
| | - Linda G Leithe
- Department of Radiology, Duke University Health System, Durham, NC
| | - Ehsan Samei
- Department of Radiology, Duke University Health System, Durham, NC
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Galvan J, Maya M, Prasad RS, Wadhwa VS, Schievink W. Spinal Cerebrospinal Fluid Leak Localization with Digital Subtraction Myelography: Tips, Tricks, and Pitfalls. Radiol Clin North Am 2024; 62:321-332. [PMID: 38272624 DOI: 10.1016/j.rcl.2023.10.004] [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: 01/27/2024]
Abstract
Cerebrospinal fluid (CSF) leak can cause spontaneous intracranial hypotension (SIH) which can lead to neurologic symptoms, such as orthostatic headache. Over time, imaging techniques for detecting and localizing CSF leaks have improved. These techniques include computed tomography (CT) myelography, dynamic CT myelography, cone-beam CT, MRI, MR myelography, and digital subtraction myelography (DSM). DSM provides the highest sensitivity for identifying leak sites and has comparable radiation exposure to CT myelography. The introduction of the lateral decubitus DSM has proven invaluable in localizing leaks when other imaging tests have been inconclusive.
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Affiliation(s)
- Javier Galvan
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Marcel Maya
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048.
| | - Ravi S Prasad
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Vikram S Wadhwa
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Wouter Schievink
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048; Department of Neurosurgery, Cedars-Sinai Medical Center
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Cirillo L, Verna F, Princiotta C, Dall’Olio M, Rustici A, Bortolotti C, Badaloni F, Mascarella D, Cortelli P, Cevoli S. Spontaneous Intracranial Hypotension and Subdural Hematomas Treatment Management Using MMA Embolization and Target Blood Patch: A Case Report. Life (Basel) 2024; 14:250. [PMID: 38398759 PMCID: PMC10890540 DOI: 10.3390/life14020250] [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: 01/02/2024] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
We report a patient suffering from spontaneous intracranial hypotension (SIH) who, following a non-selective lumbar blood patch, returned to his healthcare provider with severe symptoms of neurological deficits. It was subsequently discovered that the aforementioned deficits were due to a bilateral subdural hematoma, and an emergency surgical drainage of the hematoma has been performed. However, the hematoma reformed and potential cerebrospinal fluid leakage was consequently investigated through myelography. Following the diagnostic finding of a venous diverticulum, a selective blood patch was executed in the affected area, and in order to stabilize the hematoma, an embolization of the middle meningeal arteries was performed. The combination of such operations allowed for the resorption of the hematoma and the improvement of neurological symptoms.
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Affiliation(s)
- Luigi Cirillo
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Francesca Verna
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Ciro Princiotta
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
| | - Massimo Dall’Olio
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
| | - Arianna Rustici
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Carlo Bortolotti
- UO Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (C.B.); (F.B.)
| | - Filippo Badaloni
- UO Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (C.B.); (F.B.)
| | - Davide Mascarella
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
| | - Pietro Cortelli
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
| | - Sabina Cevoli
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
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11
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Chen L, Wu H, Hu X, Ying G. Acquired tonsillar herniation related to spontaneous intracranial hypotension: case reports. Front Neurol 2024; 15:1309718. [PMID: 38327627 PMCID: PMC10847289 DOI: 10.3389/fneur.2024.1309718] [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: 10/10/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Background Acquired prolapse of the cerebellar tonsils in spontaneous intracranial hypotension (SIH) patients is rare. This study aims to evaluate neuroimaging changes of acquired prolapse of the cerebellar tonsils below the foramen magnum in SIH patients due to spontaneous spinal cerebrospinal fluid leakage, which was treated by targeted epidural blood patches (EBP). Methods We retrospectively reviewed clinical and neuroimaging characteristics of 5 cases of SIH with acquired prolapse of the cerebellar tonsils that received targeted EBP in our institution from January 2013 to December 2016. Results Of these SIH patients, all of them suffered from an orthostatic headache. Initial cranial MRI demonstrated descent of the cerebellar tonsils ≥5 mm. Intrathecal gadolinium-enhanced spinal MR myelography and/or spinal MR hydrography were performed to evaluate the level of spinal cerebrospinal fluid leakage. Symptoms were alleviated in all 5 patients after two (n = 4), or three (n = 1) targeted EBP during hospitalization. Follow-up cranial MRI revealed that the descent of cerebellar tonsils was reversed after EBP treatment. Conclusion Acquired tonsillar herniation can occur in patients with SIH and spinal cerebrospinal fluid leakage. Symptoms of these patients may be resolved and radiologic findings may be reversed after EBP treatment.
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Affiliation(s)
- Lili Chen
- Department of Neurology, Xiasha Campus, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haijian Wu
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xingyue Hu
- Department of Neurology, Xiasha Campus, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guangyu Ying
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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12
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Goddu Govindappa SK, Adiga CP, Kumar S, Goolahally LN, Kumar S. Spontaneous Intracranial Hypotension: A Review of Neuroimaging and Current Concepts. Indian J Radiol Imaging 2024; 34:128-138. [PMID: 38106851 PMCID: PMC10723964 DOI: 10.1055/s-0043-1774301] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Spontaneous intracranial hypotension (SICH) is the emerging cause of orthostatic headache as it has been better recognized in recent years. SICH happens due to spinal cerebrospinal fluid (CSF) leak; however, the manifestations are predominantly cranial and hence imaging in SICH includes brain and spine. There are few characteristic brain imaging features to be concerned about to diagnose SICH in patients with vague symptoms or low clinical suspicion. Spine screening is recommended in these patients to assess spinal CSF leaks. While neuroradiologists play a significant role from the time of diagnosis to treatment of SICH, there is a need for all the general radiologists to be aware of the condition. Computed tomography myelogram and digital subtraction myelogram are performed for diagnostic and therapeutic management of SICH. There is a known risk for SICH recurrence in patients with sagittal longitudinal epidural collection and hence, targeted blood patch should be used instead of blind patch. Most importantly, slow mobilization is recommended following the patch to avoid recurrence.
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Affiliation(s)
| | | | - Savith Kumar
- Department of Radiology, Apollo Hospitals, Sheshadripuram, Bangalore, Karnataka, India
| | | | - Sujit Kumar
- Department of Neurology, Apollo Hospitals, Sheshadripuram, Bangalore, Karnataka, India
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13
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Yoo HJ. [Spinal Presentation of Spontaneous Intracranial Hypotension]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:24-35. [PMID: 38362391 PMCID: PMC10864159 DOI: 10.3348/jksr.2023.0151] [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: 12/04/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 02/17/2024]
Abstract
Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and heightened awareness. Many prior studies have reported the characteristic brain MRI findings of SIH. However, recently, focus has shifted to spinal MRI, as SIH is believed to be caused by leakage of cerebrospinal fluid from the spinal dural sac. Advanced techniques such as ultrafast CT myelography and digital subtraction myelography have emerged as useful technique to identify the site of cerebrospinal fluid leakage. In this review, we discuss the diagnosis, spinal MRI findings, imaging techniques, and treatment of SIH.
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14
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Cordeiro de Macedo Pontes Í, Leão Edelmuth DG, Takahara S, Noda Kihara Filho E, Lucato LT, Partezani Helito PV, Kranz PG. CT Myelography: How to Do It. Radiographics 2024; 44:e230088. [PMID: 38096111 DOI: 10.1148/rg.230088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Írline Cordeiro de Macedo Pontes
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Diogo Guilherme Leão Edelmuth
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Stephanie Takahara
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Eduardo Noda Kihara Filho
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Leandro Tavares Lucato
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Paulo Victor Partezani Helito
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
| | - Peter G Kranz
- From the Department of Radiology, Hospital das Clínicas da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 Cerqueira César, São Paulo, SP 05403-010, Brazil (I.C.d.M.P., D.G.L.E., S.T., L.T.L., P.V.P.H.); Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil (D.G.L.E.); Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil (I.C.d.M.P., D.G.L.E., E.N.K.F.); and Department of Radiology, Duke University Medical Center, Durham, NC (P.G.K.)
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15
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Lins LAB, Birch CM, Berde C, Emans J, Hedequist D, Hresko MT, Karlin L, Glotzbecker MP. Late-presenting dural leak following spine fusion in the pediatric population. Spine Deform 2023; 11:1371-1380. [PMID: 37488330 DOI: 10.1007/s43390-023-00720-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 06/10/2023] [Indexed: 07/26/2023]
Abstract
PURPOSE The purpose is to describe how patients with a late-presenting dural leak (LPDL) after posterior spinal fusion (PSF) was diagnosed and treated at a single institution. METHODS Of the 1991 patients who underwent a PSF between 2010 and 2018, 6 patients were identified with a clinical course consistent with a potential LPDL. RESULTS Six patients with median age 16.9 years had onset of headache ranging 1-12 weeks postoperatively (median 6.5 weeks). All six patients presented with positional headache, and half (3/6) presented with emesis. 5/6 patients underwent contrast brain MRI, which demonstrated pachymeningeal enhancement. 4/5 patients with dural enhancement went on to have CT myelogram. Five patients had a CT myelogram, which identified a dural leak in all patients and localized the leak in four of five patients. All patients underwent an epidural blood patch, which resolved the pain in five patients. One patient without relief underwent revision surgery with removal of a medially placed screw and fibrin glue placement resolving symptoms. CONCLUSIONS Postoperative dural leaks associated with PSF may present in a delayed fashion. The majority of leaks were not associated with screw malposition. In diagnosing patients with suspected LPDL, we suggest brain MRI with contrast as a first step. Most patients with pachymeningeal enhancement shown on contrast brain MRI had dural leaks that were identified through CT myelograms. For patients with a dural leak, if there is no disruption from screws, a blood patch appears to be an effective treatment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Laura A B Lins
- Department of Orthopedics and Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI, USA.
| | - Craig M Birch
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Charles Berde
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - John Emans
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Daniel Hedequist
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - M Timothy Hresko
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Lawrence Karlin
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michael P Glotzbecker
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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16
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Lützen N, Barvulsky Aleman E, Fung C, Beck J, Urbach H. Prone Dynamic CT Myelography in Spontaneous Intracranial Hypotension : Diagnostic Need and Radiation Doses. Clin Neuroradiol 2023; 33:739-745. [PMID: 36867243 PMCID: PMC10449968 DOI: 10.1007/s00062-023-01269-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/25/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND AND PURPOSE The diagnostic work-up in patients with spontaneous intracranial hypotension (SIH) and spinal longitudinal extradural CSF collection (SLEC) on magnetic resonance imaging (MRI) comprises dynamic digital subtraction myelography (dDSM) in prone position for leak detection. Dynamic computed tomography (CT) myelography (dCT-M) in prone position follows if the leak is not unequivocally located. A drawback of dCT‑M is a high radiation dose. This study evaluates the diagnostic needs of dCT-M examinations and measures to reduce radiation doses. METHODS Frequency, leak sites, length and number of spiral acquisitions, DLP and effective doses of dCT‑M were retrospectively recorded in patients with ventral dural tears. RESULTS Of 42 patients with ventral dural tears, 8 underwent 11 dCT‑M when the leak was not unequivocally shown on digital subtraction myelography. The median number of spiral acquisitions was 4 (range 3-7) and the mean effective radiation dose 30.6 mSv (range 13.1-62.16 mSv) mSv. Five of eight leaks were located in the upper thoracic spine (range C7/Th1-Th2/3). Bolus tracking of intrathecal contrast agent in dCT‑M was used to limit the number and length of spiral acquisitions. DISCUSSION A dCT‑M in prone position to localize a ventral dural tear is needed in every fifth patient with a SLEC on MRI. It is typically needed when the leak is located in the upper thoracic spine and when patients have broad shoulders. Measures to reduce the radiation dose include bolus tracking or to repeat the DSM with adjusted positioning of patient.
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Affiliation(s)
- Niklas Lützen
- Dept. of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Enrique Barvulsky Aleman
- Dept. of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Christian Fung
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juergen Beck
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Dept. of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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17
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Wagle S, Benson JC, Madhavan AA, Carr CM, Garza I, Diehn FE, Kim DK. The clue is in the kidneys: greater renal contrast medium accumulation on ipsilateral side down CT myelogram after lateral decubitus digital subtraction myelogram as a predictor of laterality of cerebrospinal fluid leak. Clin Radiol 2023:S0009-9260(23)00173-3. [PMID: 37225571 DOI: 10.1016/j.crad.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 03/31/2023] [Accepted: 04/23/2023] [Indexed: 05/26/2023]
Abstract
AIM To assess the potential correlation of the laterality of a cerebrospinal fluid (CSF)-venous fistula with the laterality of decubitus computed tomography (CT) myelogram (post decubitus digital subtraction myelogram) based on which side demonstrated more renal contrast medium excretion. MATERIALS AND METHODS Patients with CSF-venous fistulas diagnosed at lateral decubitus digital subtraction myelograms were reviewed retrospectively. Patients who did not have CT myelogram following one or both left and right lateral decubitus digital subtraction myelograms were excluded. Two neuroradiologists independently interpreted the CT myelogram for the presence or absence of renal contrast, and whether subjectively more renal contrast medium was visualised on the left or right lateral decubitus CT myelogram. RESULTS Renal contrast medium was seen in lateral decubitus CT myelograms in 28 of 30 (93.3%) patients with CSF-venous fistulas. Having more renal contrast medium in right lateral decubitus CT myelogram was 73.9% sensitive and 71.4% specific for the diagnosis of a right-sided CSF-venous fistula, whereas having more renal contrast medium in the left lateral decubitus CT myelogram was 71.4% sensitive and 82.6% specific for a left-sided CSF-venous fistula (p=0.02). CONCLUSION When the CSF-venous fistula lies on the dependent side of a decubitus CT myelogram performed after decubitus digital subtraction myelogram, relatively more renal contrast medium is visualised compared to when the fistula lies on the non-dependent side.
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Affiliation(s)
- S Wagle
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - J C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| | - A A Madhavan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - C M Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - I Garza
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - F E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - D K Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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18
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Bin Wan Hassan WMN, Mistretta F, Molinaro S, Russo R, Bosco G, Gambino A, Bergui M. Overview of Spontaneous Intracranial Hypotension and Differential Diagnosis with Chiari I Malformation. J Clin Med 2023; 12:jcm12093287. [PMID: 37176727 PMCID: PMC10179697 DOI: 10.3390/jcm12093287] [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: 02/15/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.
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Affiliation(s)
| | - Francesco Mistretta
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Giovanni Bosco
- Department of Neuroscience, Stroke Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Andrea Gambino
- Department of Surgical Sciences, Radiology Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
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19
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Rajpal S, Nambiar M, Castanelli D, Khabaza A, Asadi H, Jhamb A, Mark Brooks D, Maingard J. Spontaneous Intracranial Hypotension and Spinal Epidural CSF Leaks: Diagnosis and Management. J Clin Neurosci 2023; 111:46-56. [PMID: 36948109 DOI: 10.1016/j.jocn.2023.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/22/2023]
Abstract
Spontaneous intracranial hypotension from spinal cerebrospinal fluid leak is a condition that often presents as orthostatic headaches. Diagnosis and localisation of spinal CSF leaks remain difficult despite multiple imaging modalities that can be used to aid identification. These include traditional CT myelography and MRI as well as newer techniques such as dynamic and digital subtraction myelography. Leaks can be classified into types and optimal localisation and management techniques vary by type of leak. Localisation of a leak can aid in targeting treatment such as an epidural blood patch if conservative measures fail. Where unsuccessful, repeated blood patches and novel techniques can be used to improve patient symptoms. Much of this condition is not well understood and evidence is lacking, with many avenues for potential research.
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Affiliation(s)
- Simran Rajpal
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Victoria, Australia.
| | - Mithun Nambiar
- Monash Imaging, Monash Health, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Damian Castanelli
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Ali Khabaza
- Monash Imaging, Monash Health, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Hamed Asadi
- Department of Neuro-Interventional Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia; School of Medicine, Deakin University, Waurn Ponds, Geelong, Victoria, Australia
| | - Ash Jhamb
- Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Neuro-Interventional Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Julian Maingard
- Department of Neuro-Interventional Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia; School of Medicine, Deakin University, Waurn Ponds, Geelong, Victoria, Australia
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20
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Mehta D, Cheema S, Davagnanam I, Matharu M. Diagnosis and treatment evaluation in patients with spontaneous intracranial hypotension. Front Neurol 2023; 14:1145949. [PMID: 36970531 PMCID: PMC10036855 DOI: 10.3389/fneur.2023.1145949] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Spontaneous intracranial hypotension is characterized by an orthostatic headache and audiovestibular symptoms alongside a myriad of other non-specific symptoms. It is caused by an unregulated loss of cerebrospinal fluid at the spinal level. Indirect features of CSF leaks are seen on brain imaging as signs of intracranial hypotension and/or CSF hypovolaemia as well as a low opening pressure on lumbar puncture. Direct evidence of CSF leaks can frequently, but not invariably, be observed on spinal imaging. The condition is frequently misdiagnosed due to its vague symptoms and a lack of awareness of the condition amongst the non-neurological specialities. There is also a distinct lack of consensus on which of the many investigative and treatment options available to use when managing suspected CSF leaks. The aim of this article is to review the current literature on spontaneous intracranial hypotension and its clinical presentation, preferred investigation modalities, and most efficacious treatment options. By doing so, we hope to provide a framework on how to approach a patient with suspected spontaneous intracranial hypotension and help minimize diagnostic and treatment delays in order to improve clinical outcomes.
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Affiliation(s)
- Dwij Mehta
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- *Correspondence: Dwij Mehta
| | - Sanjay Cheema
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Indran Davagnanam
- Lysholm Department of Neuroradiology, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Manjit Matharu
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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21
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Hill D, Buchbinder B, Pomerantz S, Mehan WA, Buch K. The "Crossing Collection Sign": A Diagnostic Tool on Spine Magnetic Resonance Imaging For Localizing Cerebrospinal Fluid Leak. J Comput Assist Tomogr 2023; 47:337-342. [PMID: 36877758 DOI: 10.1097/rct.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVE The aim of the study is to determine whether the site of "cross" between ventral and dorsal spinal longitudinal extradural CSF collections (SLECs) seen on magnetic resonance imaging during initial workup of patients with suspected CSF leaks can predict the subsequently confirmed leakage site on computed tomography myelography or surgical repair. METHODS This was an institutional review board-approved, retrospective study performed from 2006 to 2021. Patients with SLECs who underwent total spine magnetic resonance imaging at our institution, followed by myelography and/or surgical repair for CSF leak, were included. Patients with incomplete workup including lack of computed tomography myelography and/or surgical repair and patients severely motion degraded imaging were excluded from our study. The site of cross between ventral and dorsal SLECs was defined as the "crossing collection sign" and was compared with the anatomically confirmed site of leak on myelography and/or at surgical repair. RESULTS Thirthy-eight patients met inclusion criteria with 18 females and 11 males ranging in age from 27 to 60 years (median, 40 years; interquartile range, 14 years). The crossing collection sign was seen in 76% of patients (n = 29). The distributions of confirmed CSF leak were as follows: cervical (n = 9), thoracic (n = 17), and lumbar spine (n = 3). The crossing collection sign predicted the site of CSF leak in 14 of 29 patients (48%) and was within 3-vertebral segments in 26 of 29 cases (90%). CONCLUSIONS The crossing collection sign can help prospectively identify spinal regions with highest likelihood for CSF leak in patients with SLECs. This can potentially help optimize the more invasive subsequent steps in the workup for these patients, including dynamic myelography and surgical exploration for repair.
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Affiliation(s)
- Daniel Hill
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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22
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Moreira DG, Félix EPV, Onishi FJ, Ferraz HB, Coradine TLC, Braga VL, Oliveira EMLD. Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:128-133. [PMID: 36863400 PMCID: PMC10033192 DOI: 10.1055/s-0042-1758752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
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.
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Affiliation(s)
- Daniel Gabay Moreira
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Franz Jooji Onishi
- Universidade Federal de São Paulo, Departamento de Neurocirurgia, São Paulo SP, Brazil
| | | | | | - Vinícius Lopes Braga
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
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MORIYAMA E, ISHIKAWA S. Dural Entry Point of the Vertebral Artery: An Overlooked Route of Spinal CSF Leaks. NMC Case Rep J 2022; 9:1-5. [PMID: 35340334 PMCID: PMC8906836 DOI: 10.2176/jns-nmc.2021-0265] [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: 08/14/2021] [Accepted: 11/18/2021] [Indexed: 11/20/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is no longer considered rare. Its estimated annual incidence is 5 cases per 100,000 individuals, which is half the incidence of subarachnoid hemorrhage. Epidural blood patch (EBP) is indicated for SIH patients who do not improve with conservative treatment. Accurate determination of the cerebrospinal fluid (CSF) leak site is critical for a successfully targeted EBP. We report the case of a 43-year-old woman with SIH secondary to CSF leakage at the craniovertebral junction dural entry point of the vertebral artery (VA). We treated the patient 2 months after the onset of symptoms. Fat-suppressed T2-weighted spinal magnetic resonance (MR) images revealed a massive epidural fluid collection around the upper thoracic spine. Extravasation of contrast medium through the left VA-dural entry point was clearly visible on computed tomographic myelography. A cervical EBP was injected through the C1-2 interlaminar space. The patient had a smooth recovery and was asymptomatic, with normal spinal MR findings, 6 months after treatment. The possibility of CSF leakage from the dural entry point of the VA should be considered in SIH patients. EBP targeted at the VA entry point is proposed as a safe and effective treatment.
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Affiliation(s)
- Eiji MORIYAMA
- Department of Neurosurgery, National Hospital Organization Fukuyama Medical Center
| | - Shinichi ISHIKAWA
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital
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Abdelrahman A, Bizilis JC, Davies S, Bala A. Management of spontaneous cerebrospinal fluid leakage: A surgical case series. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Leung LWL, Chan YCD, Chan TMD. Lumbar epidural blood patch: An effective treatment for intracranial hypotension. Surg Neurol Int 2022; 13:517. [DOI: 10.25259/sni_795_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
The literature has demonstrated the efficacy of lumbar epidural blood patch (LEBP) in the management of spontaneous intracranial hypotension (SIH). However, the underlying pathophysiology of such management remains unclear. In this study, we aim to evaluate the utility of LEBP injections in the management of SIH and develop a potential management algorithm used in the triage and management of SIH patients.
Methods:
We retrospectively examined the clinical case notes of 14 patients with SIH (age: 25–69 years) who were managed with LEBP injections during the year of 2016–2021. We evaluated the presenting symptoms of each selected patient and radiological findings as well as treatment outcomes. Our aim is to evaluate the effectiveness of LEBP in the treatment of SIH patients through follow-up clinical and imaging assessment.
Results:
About 93% of patients describe the presence of headache at presentation, while 43% describe it as being of an orthostatic nature. All patients demonstrated typical findings on magnetic resonance imaging brain. Treatment success assessed through symptomatic improvement and radiological resolution was found in 85% of our patients at a 2-month interval.
Conclusion:
LEBP injection is an effective method of management in patients with a diagnosis of SIH. It should be considered in all SIH patients irrespective of whether a “dural leak” can be localized through radiological investigations.
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Lee SJ, Kim D, Suh CH, Shim WH, Heo H, Jo S, Chung SJ, Kim HS, Kim SJ. Detection rate of MR myelography without intrathecal gadolinium in patients with newly diagnosed spontaneous intracranial hypotension. Clin Radiol 2022; 77:848-854. [PMID: 35985843 DOI: 10.1016/j.crad.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/16/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the detection rate of magnetic resonance (MR) myelography without intrathecal gadolinium for cerebrospinal fluid (CSF) leakage in patients with newly diagnosed spontaneous intracranial hypotension (SIH) and to validate a published scoring system for predicting CSF leakage. MATERIALS AND METHODS This retrospective, observational, single-institution study included patients with newly diagnosed SIH between March 2015 and April 2021. Patients were included if they (a) had newly diagnosed SIH and (b) underwent initial brain MR imaging and preprocedural MR myelography with two- and three-dimensional turbo spin-echo sequences. Patients who underwent spine surgery or procedures including epidural injection and acupuncture were excluded. The detection rate was defined as the proportion of patients with a true-positive MR myelography result among all patients with confirmed CSF leakage. The interobserver agreement for the MR myelography results between two radiologists was analysed using weighted kappa statistics. RESULTS A total of 136 patients (mean age, 48 years; 70 women) with suspected SIH were included. Of these patients, 120 (88%, 120/136) were confirmed to have CSF leakage. Of the patients with confirmed CSF leakage, 90 (75%, 90/120) had epidural fluid collection. The detection rate of MR myelography for CSF leakage was 88% (105/120). The interobserver agreement between the two readers for detecting CSF leakage (κ = 0.76) or epidural fluid collection (κ = 0.76) on MR myelography was high. Among 24 patients with normal brain MR imaging results, 16 had CSF leakage (67%, 16/24). CONCLUSIONS Non-invasive MR myelography without intrathecal gadolinium should be considered to detect CSF leakage in patients with suspected SIH.
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Affiliation(s)
- S J Lee
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D Kim
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C H Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - W H Shim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - H Heo
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S Jo
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S J Chung
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - H S Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S J Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension: a systematic review and meta-analysis. Eur Radiol 2022; 32:7843-7853. [PMID: 35538263 DOI: 10.1007/s00330-022-08845-w] [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: 10/31/2021] [Revised: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 01/03/2023]
Abstract
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.
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Huls SJ, Shlapak DP, Kim DK, Leng S, Carr CM. Utility of Dual-Energy CT to Improve Diagnosis of CSF Leaks on CT Myelography following Lateral Decubitus Digital Subtraction Myelography with Negative Findings. AJNR Am J Neuroradiol 2022; 43:1539-1543. [PMID: 36574327 PMCID: PMC9575522 DOI: 10.3174/ajnr.a7628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/12/2022] [Indexed: 01/26/2023]
Abstract
CSF leaks, including CSF-venous fistulas, which cause spontaneous intracranial hypotension, remain difficult to diagnose, even on digital subtraction myelography and CT myelography. Dual-energy CT technology has been used to improve diagnostic utility within multiple organ systems. The capability of dual-energy CT to create virtual monoenergetic images can be leveraged to increase conspicuity of contrast in CSF-venous fistulas and direct epidural CSF leakage to improve the diagnostic utility of CT myelography. Six cases (in 5 patients) are shown in which virtual monoenergetic images demonstrate a leak location that was either occult or poorly visible on high- or low-kilovolt series. This clinical report describes the novel application of dual-energy CT for the detection of subtle CSF leaks including CSF-venous fistulas.
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Affiliation(s)
- S J Huls
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - D P Shlapak
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - D K Kim
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - S Leng
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
| | - C M Carr
- From the Department of Radiology, Mayo Clinic, Ringgold Standard Institution, Rochester, Minnesota
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Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [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: 12/02/2022]
Abstract
INTRODUCTION Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed. AREAS COVERED The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes. EXPERT OPINION The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.
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Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Imaging, Clinical, and Demographic Differences in Patients With Type III Spinal Cerebrospinal Fluid Leak (Cerebrospinal Venous Fistulas) Compared With Patients With Types I and II Spinal Cerebrospinal Fluid Leak. J Comput Assist Tomogr 2022; 46:986-990. [PMID: 36112050 DOI: 10.1097/rct.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Spinal cerebrospinal fluid (CSF) leaks are an underdiagnosed cause of neurologic symptoms. The most common types of spinal CSF leaks are from dural tears (type I) and meningeal diverticula (type II). Cerebrospinal fluid-venous fistulas (type III) are less common and underrecognized. The purpose of this study was to evaluate the intracranial and spinal imaging findings in patients with types I/II versus type III leaks. MATERIALS AND METHODS This was a retrospective, institutional review board-approved study performed on adult patients between January 2020 to September 2021 with surgically confirmed type I/II/III spinal CSF leak. Patients had preoperative brain magnetic resonance imaging (MRI) with contrast and medical records detailing symptoms and clinical diagnoses. Patients were excluded for nondiagnostic brain MRIs. Demographic and clinical information were recorded. The presence of extra-axial collections, pachymeningeal thickening, brain sagging, and decreased pontomamillary distance were evaluated on MRI. RESULTS Seven patients had type III leaks, and 16 had type I/II leaks. Patients with type III leaks were older (P = 0.0003) and had higher rates of initial misdiagnosis (100% vs 31%) and longer times to correct diagnosis (P = 0.03) compared with type I/II leaks. Intracranial extra-axial collections were never seen with type III leaks but were seen in 50% of type I/II leaks. Pachymeningeal thickening and brainstem sagging occurred in nearly equal frequency between groups. Smaller pontomamillary distances were seen in type III leaks versus type I/II leaks (P = 0.047). CONCLUSIONS When evaluating patients with suspected spinal CSF leak, findings of older age, absence of intracranial extra-axial collections, and small pontomamillary distances may raise suspicion for type III versus type I/II leak.
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Krivoshapkin A, Savitskiy I, Gaitan A, Savitskaya I, Sergeev G, Abdullaev O, Chesnulis E. Intracranial hypotension caused by spinal degeneration mimics clinically relevant Chiari type I malformation. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Swain A, Sahu S, Kumari R, Tripathi M. A Single-Level Epidural Blood Patch for Multiple Cerebrospinal Fluid Leaks: How it Works. Anesth Essays Res 2022; 16:416-418. [PMID: 36620106 PMCID: PMC9813988 DOI: 10.4103/aer.aer_131_22] [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: 08/15/2022] [Accepted: 09/13/2022] [Indexed: 12/13/2022] Open
Abstract
Spontaneous intracranial hypotension caused by cerebrospinal fluid (CSF) leak is a rarely encountered cause of persistent postural headaches in the absence of trauma or dural puncture. It presents with postural headache and is characterized by radiological findings of spinal CSF leak. The mainstay of management is an epidural patch with the patient's own blood (epidural blood patch [EBP]) and/or a fibrin glue product. We report here a case of spontaneous intracranial hemorrhage presenting with persistent headaches and bilateral subdural hematomas secondary to CSF leaks at multiple levels along the spinal cord, which was successfully managed with a single lumbar EBP.
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Affiliation(s)
- Amlan Swain
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Seelora Sahu
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Rashmi Kumari
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Mamlouk MD, Shen PY, Jun P, Sedrak MF. Spontaneous Spinal CSF Leaks Stratified by Age, Body Mass Index, and Spinal Level. AJNR Am J Neuroradiol 2022; 43:1068-1072. [PMID: 35738670 DOI: 10.3174/ajnr.a7548] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/29/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There are 3 main types of spinal CSF leaks, and the imaging appearances are well-reported. Specific patient demographics and spinal locations of the various types of spinal leaks are less frequently described. The purpose of this article was to stratify the various types of spontaneous CSF leaks on the basis of age, body mass index, and spinal level. MATERIALS AND METHODS Retrospective review was performed for all patients with spontaneous spinal CSF leaks identified on CT myelography. Age, body mass index, and spinal CSF leak type and level were recorded. RESULTS Sixty-five patients (37 women and 28 men) had spinal CSF leaks. Type 1 CSF leaks (dural tears) were observed in 25 patients (mean age, 44.5 years; mean body mass index, 24.3) and were most common in the upper thoracic spine (72%), particularly at the T1-T2 level (36%). Type 2 CSF leaks (ruptured meningeal diverticula) were observed in 4 patients (mean age, 45.5 years; mean body mass index, 27.5) and were all seen in the lower thoracic spine. Type 3 CSF leaks (CSF-venous fistulas) were observed in 36 patients (mean age, 58.8 years; mean body mass index, 27.0) and were most common on the right side (72%) and in the lower thoracic spine (56%). CONCLUSIONS Type 1 CSF leaks occurred in younger patients with a normal body mass index, while patients with type 3 CSF leaks were relatively older and had an elevated body mass index. Type 1 leaks mostly occurred in the upper thoracic spine, and types 2 and 3 leaks mostly occurred in the lower thoracic spine.
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Affiliation(s)
- M D Mamlouk
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California .,Department of Radiology and Biomedical Imaging (M.D.M.), University of California, San Francisco, San Francisco, California
| | - P Y Shen
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - P Jun
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - M F Sedrak
- Department of Neurosurgery (M.F.S.), The Permanente Medical Group, Kaiser Permanente Medical Center, Redwood City, Redwood City, California
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Amrhein TJ, Kranz PG, Cantrell S, Deline CR, Carr CM, Kim DK, Goldstein KM, Williams JW. Efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension: an evidence map protocol. Syst Rev 2022; 11:116. [PMID: 35668484 PMCID: PMC9171943 DOI: 10.1186/s13643-022-01989-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is a debilitating disorder caused by non-iatrogenic spinal cerebrospinal fluid leaks. SIH is increasingly recognized as an important treatable cause of secondary headaches. Treatment involves either epidural blood patching or surgery, which have considerable differences in their adverse event rates, recovery times, and cost. The objective of this evidence map is to understand the breadth of studies that investigate SIH treatment efficacy and to identify knowledge gaps to inform future research. METHODS This review will consider experimental, observational, and systematic review studies that assess the efficacy of epidural blood patching and surgery for the treatment of patients with SIH. Individual case studies, clinical guidelines, editorials, protocols, and studies that do not assess an intervention will not be included. English language studies will be included without limitation based on the date of publication. Databases to be searched include MEDLINE® (via Ovid), EMBASE (via Elsevier), and Web of Science™ (via Clarivate). Study selection will be performed independently by two investigators with extracted data to include study type, the number of patients included, patient descriptors, intervention characteristics, and outcome measure used. Data will be presented through a narrative summary aided by tabular and graphical formats in a manner that aligns with the objective of the evidence mapping review. DISCUSSION The overarching goal of this evidence map is to provide an improved understanding of the breadth of studies investigating SIH treatment efficacy in the literature and to thereby identify knowledge gaps that can inform future research directions. TRIAL REGISTRATION OSF Registry https://osf.io/nwju7 .
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Affiliation(s)
- Timothy J Amrhein
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA.
| | - Peter G Kranz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sarah Cantrell
- Duke University Medical Center Library, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Carrie M Carr
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karen M Goldstein
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - John W Williams
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
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Algorithmic Multimodality Approach to Diagnosis and Treatment of Spinal CSF Leak and Venous Fistula in Patients With Spontaneous Intracranial Hypotension. AJR Am J Roentgenol 2022; 219:292-301. [PMID: 35261281 DOI: 10.2214/ajr.22.27485] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is a disorder of CSF dynamics that causes a complex clinical syndrome and severe disability. SIH is challenging to diagnose because of the variability of its presenting clinical symptoms, the potential for subtle easily overlooked imaging findings, and the need for specialized diagnostic testing. Once SIH is suggested by clinical history and/or supported by initial neuroimaging, many patients may undergo initial non-targeted epidural blood patching with variable and indefinite benefit. However, data suggest that precise localization of the CSF leak or venous fistula (CVF) can lead to more effective and durable treatment strategies. Leak localization can be achieved using a variety of advanced diagnostic imaging techniques, although these may not be widely performed at non-tertiary medical centers, leaving many patients with the potential for inadequate workup or treatment. This review describes imaging techniques including dynamic fluoroscopic and CT myelography as well as delayed MR myelography, and treatment options including percutaneous, endovascular, and surgical approaches, for SIH. These are summarized by an algorithmic framework for radiologists to approach the workup and treatment of patients with suspected SIH. The importance of a multidisciplinary approach is emphasized.
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Multimodality Multisystem Imaging of Pregnancy-Related Changes: Featuring Neurologic, Cardiothoracic, Breast, Gynecologic, and Musculoskeletal Issues. J Comput Assist Tomogr 2022; 46:282-293. [PMID: 35297584 DOI: 10.1097/rct.0000000000001272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Pregnancy and the puerperium are a time of significant physiologic change, and with an average of 4 million births in the United States yearly, radiologists encounter pregnancy-related imaging findings regularly. While many of these findings represent physiologic changes, a significant number represent pathology, making it paramount for radiologists to distinguish between the two. This case-based article reviews imaging findings within the nervous, cardiovascular, pulmonary, breast, gynecologic, musculoskeletal, digestive, hematologic, and integumentary systems throughout pregnancy and the postpartum period.
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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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Spontaneous intracranial hypotension: the role of radiology in diagnosis and management. Clin Radiol 2021; 77:e181-e194. [PMID: 34949452 DOI: 10.1016/j.crad.2021.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/09/2021] [Indexed: 12/26/2022]
Abstract
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.
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Incidence of Spinal CSF Leakage on CT Myelography in Patients with Nontraumatic Intracranial Subdural Hematoma. Diagnostics (Basel) 2021; 11:diagnostics11122278. [PMID: 34943515 PMCID: PMC8699929 DOI: 10.3390/diagnostics11122278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 01/24/2023] Open
Abstract
The aim of the present study was to demonstrate the incidence of spinal cerebrospinal fluid (CSF) leaks in patients with nontraumatic intracranial subdural hematoma (SDH) and determine clinical parameters favoring such leaks. This retrospective study was approved by the institutional review board. Patients diagnosed with nontraumatic intracranial SDH who underwent computed tomography (CT) myelography between January 2012 and March 2018 were selected. 60 patients (male: female, 39:21; age range, 20–82 years) were enrolled and divided into CSF leak-positive and CSF leak-negative groups according to CT myelography data. Clinical findings were statistically compared between the two groups. Spinal CSF leak was observed in 80% (48/60) of patients, and it was significantly associated with an age of <69 years (p = 0.006). However, patients aged ≥69 years also had a tendency to exhibit spontaneous intracranial hypotension (SIH)-induced nontraumatic intracranial SDH (60.87%; 14/23). Therefore, CT myelography is recommended to be performed for the evaluation of possible SIH in patients with nontraumatic intracranial SDH, particularly those aged <69 years. Patients aged ≥69 years are also good candidates for CT myelography because SIH tends to occur even in this age group.
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Gordon C, Fry C, Salman M, Desai N. Meningitis following cerebrospinal fluid-cutaneous fistula secondary to combined spinal-epidural anaesthesia for elective caesarean delivery. Int J Obstet Anesth 2021; 49:103241. [PMID: 34906428 DOI: 10.1016/j.ijoa.2021.103241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/31/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Cerebrospinal fluid-cutaneous fistula is a rare complication associated with neuraxial procedures. Here, we describe a case of fistula formation related to combined spinal-epidural anaesthesia for elective caesarean delivery, where the epidural catheter was removed only two hours later. The clear fluid leaking persistently from the site of the skin puncture associated with the epidural insertion site was confirmed to be cerebrospinal fluid with an increased beta-trace protein, and the fistula was closed with skin sutures. Subsequently, the patient presented with neurological signs and symptoms consistent with meningitis and she was treated empirically with intravenous antibiotics. Cerebrospinal fluid-cutaneous fistula formation with secondary meningitis is an exceptionally rare event in obstetric anaesthesia.
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Affiliation(s)
- C Gordon
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C Fry
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M Salman
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N Desai
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK.
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Majeed K, Hanz SZ, Roytman M, Chazen JL, Greenfield JP. Identification and surgical ligation of spinal CSF-venous fistula. Surg Neurol Int 2021; 12:514. [PMID: 34754564 PMCID: PMC8571184 DOI: 10.25259/sni_539_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background: CSF-venous fistulas (CVF) may cause incapacitating positional headaches resulting from spontaneous intracranial hypotension/hypovolemia (SIH). Their etiology remains unknown, although unrecognized local trauma may precipitate SIH. In addition, they are diagnostically challenging despite various imaging tools available. Here, we present CVF identification using magnetic resonance myelography (MRM) and elaborate on their surgical management techniques. Methods: Retrospective charts of confirmed and treated CVF patients with attention to their diagnostic imaging modalities and management techniques were further reviewed. Results: Six cases were identified of which three are presented here. There were two females and one male patient. All had fistulas on the left side. Two were at T7-T8 while the third was at T9-T10 level. Two underwent hemilaminotomies at the T7-T8 while the third underwent a foraminotomy at T9 level to access the fistula site. All CVF were closed with a combination of an aneurysm clip and a silk tie. On follow-up, all had complete resolution of symptoms with no evidence of recurrence. Conclusion: Of the various imaging modalities available, MRM is particularly sensitive in localizing CVF spinal nerve level and their laterality. In addition, the technique of aneurysm clip ligation and placement of a silk tie is curative for these lesions.
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Affiliation(s)
- Kashif Majeed
- Department of Neurological Surgery Weill Cornell Medicine, New York City, New York, United States
| | - Samuel Z Hanz
- Department of Neurological Surgery Weill Cornell Medicine, New York City, New York, United States
| | - Michelle Roytman
- Department of Radiology, Division of Neuroradiology, Weill Cornell Medicine, New York City, New York, United States
| | - J Levi Chazen
- Department of Radiology, Division of Neuroradiology, Weill Cornell Medicine, New York City, New York, United States
| | - Jeffrey P Greenfield
- Department of Neurological Surgery Weill Cornell Medicine, New York City, New York, United States
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Houk JL, Amrhein TJ, Gray L, Malinzak MD, Kranz PG. Differentiation of Chiari malformation type 1 and spontaneous intracranial hypotension using objective measurements of midbrain sagging. J Neurosurg 2021:1-8. [PMID: 34715671 DOI: 10.3171/2021.6.jns211010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari malformation type 1 (CM-1) and spontaneous intracranial hypotension (SIH) are causes of headache in which cerebellar tonsillar ectopia (TE) may be present. An accurate method for differentiating these conditions on imaging is needed to avoid diagnostic confusion. Here, the authors sought to determine whether objective measurements of midbrain morphology could distinguish CM-1 from SIH on brain MRI. METHODS This is a retrospective case-control series comparing neuroimaging in consecutive adult subjects with CM-1 and SIH. Measurements obtained from brain MRI included previously reported measures of brain sagging: TE, slope of the third ventricular floor (3VF), pontomesencephalic angle (PMA), mamillopontine distance, lateral ventricular angle, internal cerebral vein-vein of Galen angle, and displacement of iter (DOI). Clivus length (CL), an indicator of posterior fossa size, was also measured. Measurements for the CM-1 group were compared to those for the entire SIH population (SIHall) as well as a subgroup of SIH patients with > 5 mm of TE (SIHTE subgroup). RESULTS Highly significant differences were observed between SIHall and CM-1 groups in the following measures: TE (mean ± standard deviation, 3.1 ± 5.7 vs 9.3 ± 3.5 mm), 3VF (-16.8° ± 11.2° vs -2.1° ± 4.6°), PMA (44.8° ± 13.1° vs 62.7° ± 9.8°), DOI (0.2 ± 4.1 vs 3.8 ± 1.6 mm), and CL (38.3 ± 4.5 vs 44.0 ± 3.3 mm; all p < 0.0001). Eight (16%) of 50 SIH subjects had TE > 5 mm; in this subgroup (SIHTE), a cutoff value of < -15° for 3VF and < 45° for PMA perfectly discriminated SIH from CM-1 (sensitivity and specificity = 1.0). DOI showed perfect specificity (1.0) in detecting SIH among both groups. No subjects with SIH had isolated TE without other concurrent findings of midbrain sagging. CONCLUSIONS Measures of midbrain sagging, including cutoff values for 3VF and PMA, discriminate CM-1 from SIH and may help to prevent misdiagnosis and unnecessary surgery.
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Affiliation(s)
- Jessica L Houk
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Timothy J Amrhein
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Linda Gray
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Michael D Malinzak
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Peter G Kranz
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
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Editorial Comment: Spontaneous Intracranial Hypotension-A Challenging Diagnosis That Requires Persistence and Expertise. AJR Am J Roentgenol 2021; 217:1430. [PMID: 34704456 DOI: 10.2214/ajr.21.26500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Radu RA, Terecoasa EO, Marinescu AN, Enache I, Tiu C. Cranial cerebrospinal fluid leak and intracranial hypotension syndrome - a case report. J Med Life 2021; 14:587-590. [PMID: 34621386 PMCID: PMC8485374 DOI: 10.25122/jml-2021-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/16/2021] [Indexed: 11/17/2022] Open
Abstract
Spontaneous intracranial hypotension is a rare clinical entity caused in most cases by a cerebrospinal fluid leak occurring at the level of the spinal cord. Cranial dural leaks have been previously reported as a cause of orthostatic headaches but, as opposed to spinal dural leaks, were not associated with other findings characteristic of spontaneous intracranial hypotension. We present the case of a male admitted for severe orthostatic headache. The patient had a history of intermittent postural headaches, dizziness, and symptoms consistent with post-nasal drip, which appeared several years after head trauma. Brain imaging showed signs consistent with intracranial hypotension: bilateral hygromas, subarachnoid hemorrhage, superficial siderosis, diffuse contrast enhancement of the pachymeninges, and superior sagittal sinus engorgement. No spinal leak could be identified by magnetic resonance imaging, and the patient had a rapid remission of symptoms with conservative management. Further work-up identified an old temporal bone fracture which created a route of egress between the posterior fossa and the mastoid cells. Otorhinolaryngology examination showed pulsatile bloody discharge and liquorrhea at the level of the left pharyngeal opening of the Eustachian tube. The orthostatic character of the headache, as well as the brain imaging findings, were consistent with intracranial hypotension syndrome caused by a cranial dural leak. Clinical signs and imaging findings consistent with the diagnosis of apparently “spontaneous” intracranial hypotension should prompt the search for a cranial dural leak if a spinal leak is not identified.
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Affiliation(s)
- Razvan Alexandru Radu
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Neurology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Elena Oana Terecoasa
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Neurology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Nicoleta Marinescu
- Department of Radiology and Medical Imaging, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Radiology and Medical Imaging, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Iulian Enache
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Cristina Tiu
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Neurology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Kawahara T, Arita K, Fujio S, Hanaya R, Atsuchi M, Moinuddin FM, Kamil M, Okada T, Hirano H, Kitamura N, Kanda N, Yamahata H, Yoshimoto K. Dural sac shrinkage signs on magnetic resonance imaging at the thoracic level in spontaneous intracranial hypotension-its clinical significance. Acta Neurochir (Wien) 2021; 163:2685-2694. [PMID: 34415442 DOI: 10.1007/s00701-021-04933-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Takashi Kawahara
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- Department of Neurosurgery, Atsuchi Neurosurgical Hospital, Kagoshima, Japan
- Department of Neurosurgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
- Department of Neurosurgery, Izumi Regional Medical Center, Akune, Japan.
| | - Shingo Fujio
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masamichi Atsuchi
- Department of Neurosurgery, Atsuchi Neurosurgical Hospital, Kagoshima, Japan
| | - F M Moinuddin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Muhammad Kamil
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- Department of Neurologic Surgery, Airlangga University, Surabaya, Indonesia
| | - Tomohisa Okada
- Department of Neurosurgery, Izumi Regional Medical Center, Akune, Japan
| | - Hirofumi Hirano
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Naoyuki Kitamura
- Diagnostic Imaging Center, Medical Network Systems, Hiroshima, Japan
| | - Naoaki Kanda
- Department of Neurology, Imamura General Hospital, Kagoshima, Japan
| | - Hitoshi Yamahata
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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Roytman M, Ulrich CT, Chazen JL. Post-dural puncture pseudomeningocele ("arachnoid bleb"): An underrecognized etiology of spontaneous intracranial hypotension symptomatology. Clin Imaging 2021; 80:377-381. [PMID: 34517304 DOI: 10.1016/j.clinimag.2021.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an important secondary cause of a persistent headache syndrome, classically presenting as sudden onset debilitating positional headaches related to reduced intracranial cerebrospinal fluid (CSF) volume. Current understanding of SIH pathogenesis recognizes three underlying etiologies: dural tear, meningeal diverticulum, and CSF-venous fistula, with a fourth broad category of indeterminate/unknown etiologies. Post-dural puncture headache (PDPH) is a well-known and common complication of dural puncture, typically remitting spontaneously within two weeks of onset or with autologous epidural blood patch, though with some patients developing complex and difficult to manage chronic PDPH. Herein, we present a case of chronic PDPH resulting in SIH symptomatology secondary to a post-dural puncture pseudomeningocele, or "arachnoid bleb," successfully treated with curative surgical intervention. Increasing awareness of additional potential etiologies of SIH symptomatology will allow for improved detection for targeted definitive therapy, ultimately improving patient outcomes including quality of life in this debilitating and difficult to manage secondary headache syndrome.
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Affiliation(s)
- Michelle Roytman
- Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Medicine, United States of America
| | | | - J Levi Chazen
- Department of Radiology, Hospital for Special Surgery, United States of America.
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Yoon D, Cipriano PW, Penticuff R, Castillo JB, Xu Y, Carroll IR, Biswal S. Abnormal [18F]FDG PET/MRI findings in paraspinal structures of patients with suspected cerebrospinal fluid leak. Sci Rep 2021; 11:15926. [PMID: 34354104 PMCID: PMC8342579 DOI: 10.1038/s41598-021-95056-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
A combination of magnetic resonance imaging (MRI), computed tomography (CT), and radionuclide cisternography are typically used to locate a cerebrospinal fluid (CSF) leak. However, the site of leakage cannot be determined, making treatment more difficult. Therefore, more sensitive imaging tools are needed. A whole-body [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET)/MRI was conducted on six patients with suspected CSF leak and the resulting images were reviewed in comparison with those from six healthy controls. Paraspinal regions of focally increased uptake of [18F]FDG were quantified using maximum standardized uptake values (SUVmax) and compared to the SUVmax of corresponding regions in the healthy controls. All six patients with suspected CSF leak showed paraspinal regions of significantly greater [18F]FDG uptake compared to the corresponding areas in controls (P < 0.05). Two patients treated with local injections (epidural blood patches and/or epidural fibrin patches) on the site of abnormal PET/MRI findings reported temporary but significant improvement in symptoms. Our results suggest [18F]FDG PET/MRI is sensitive to abnormalities potentially due to suspected CSF leak, which are not necessarily visible on conventional MRI alone or by the standard-of-care imaging methods.
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Affiliation(s)
- Daehyun Yoon
- Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Peter William Cipriano
- Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Ryan Penticuff
- Department of Radiology, UC San Diego School of Medicine, La Jolla, CA, USA
| | | | - Yingding Xu
- Newport Harbor Radiology Associates, Irvine, CA, USA
| | - Ian Richard Carroll
- Department of Anesthesia Perioperative and Pain Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Sandip Biswal
- Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Abstract
CSF-venous fistulas (CVFs), first described in 2014, represent an important cause of spontaneous intracranial hypotension (SIH). CVFs can be challenging to detect on conventional anatomic imaging because, unlike other types of spinal CSF leak, they do not typically result in pooling of fluid in the epidural space, and imaging signs of CVF may be subtle. Specialized myelographic techniques have been developed to help with CVF identification, but these techniques are not yet widely disseminated. This article reviews the current understanding of CVFs, emphasizing correlations between venous anatomy and imaging findings as well as potential mechanisms for pathogenesis, and describes current imaging techniques used for CVF diagnosis and localization. These techniques are broadly classified into fluoroscopy-based methods, including digital subtraction myelography and dynamic myelography, as well as cross-sectional methods, including decubitus CT myelography and MR myelography with intrathecal gadolinium. Knowledge of these various options, including their relative advantages and disadvantages, is critical in the care of patients with SIH. Investigation is ongoing, and continued advances are anticipated in understanding of CVFs as well as in optimal imaging detection.
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Wang TY, Karikari IO, Amrhein TJ, Gray L, Kranz PG. Clinical Outcomes Following Surgical Ligation of Cerebrospinal Fluid-Venous Fistula in Patients With Spontaneous Intracranial Hypotension: A Prospective Case Series. Oper Neurosurg (Hagerstown) 2021; 18:239-245. [PMID: 31134267 DOI: 10.1093/ons/opz134] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 01/30/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid-venous fistula (CVF) is a recently described cause of spontaneous intracranial hypotension (SIH). Surgical ligation of CVF has been reported, but clinical outcomes are not well described. OBJECTIVE To determine the clinical efficacy of surgical ligation for treatment of CVF. METHODS Outcomes metrics were collected in this prospective, single-arm, cross-sectional investigation. Inclusion criteria were as follows: diagnosis of SIH, demonstration of CVF on myelography, and surgical treatment of CVF. Pre- and postoperative headache severity was assessed with the Headache Impact Test (HIT-6), a validated headache scale ranging from 36 (asymptomatic) to 78 (most severe). Patient satisfaction with treatment was measured with Patient Global Impression of Change (PGIC). RESULTS Twenty subjects were enrolled, with mean postoperative follow-up at 16.0 ± 9.7 mo. All CVFs were located in the thoracic region (between T4 and T12). Pretreatment headache severity was high (mean HIT-6 scores 65 ± 6). Surgical treatment resulted in marked improvement in headache severity (mean HIT-6 change of -21 ± -9, mean postoperative HIT-6 of 44 ± 8). Of subjects with baseline headache scores in the most severe category, 83% showed a major improvement in severity (transition to the lowest 2 severity categories) after surgery. All subjects (100%) reported clinically significant levels of satisfaction with treatment (PGIC score 6 or 7); 90% reported the highest level of satisfaction. There were no short- or long-term complications or 30-d readmissions. CONCLUSION Surgical ligation is highly effective for the treatment of SIH due to CVF. Larger controlled trials with longer follow-up period are indicated to better assess its long-term efficacy and safety profile.
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Affiliation(s)
- Timothy Y Wang
- Duke University Department of Neurological Surgery, Durham, North Carolina
| | - Isaac O Karikari
- Duke University Department of Neurological Surgery, Durham, North Carolina
| | | | - Linda Gray
- Duke University Department of Radiology, Durham, North Carolina
| | - Peter G Kranz
- Duke University Department of Radiology, Durham, North Carolina
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Abstract
PURPOSE OF REVIEW Spontaneous intracranial hypotension is a disorder caused by spinal CSF leakage. This article reviews the clinical presentation, diagnosis, and treatment of spontaneous intracranial hypotension. RECENT FINDINGS The hallmark symptom of spontaneous intracranial hypotension is acute orthostatic headache; however, clinical presentations can be heterogeneous. New evidence shows that lumbar puncture is not always necessary or sufficient to establish the diagnosis. Some patients may have normal opening pressure, which suggests that insufficiency of CSF volume (hypovolemia) rather than CSF pressure might be the underlying mechanism. Several neuroimaging modalities can aid in diagnosis and localization of the CSF leakage, including brain MRI, spinal MRI, CT myelography, digital subtraction myelography, and radionuclide cisternography. Complications, such as subdural hematoma, can lead to a change in the headache pattern and potentially life-threatening consequences. Conservative treatments, such as fluid supplementation, can provide temporary relief; however, epidural blood patches, especially targeted ones, are more effective and definitive. For patients with refractory spontaneous intracranial hypotension, surgical repair of spinal CSF leakages should be considered. SUMMARY Brain and spinal MRIs are important for the diagnosis and treatment of patients with spontaneous intracranial hypotension. Early treatment with epidural blood patches may be considered to shorten the disease duration and minimize the potential risk of complications.
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