Spinal manifestations of spontaneous intracranial hypotension

Bibrachial amyotrophy as a rare manifestation of intraspinal fluid collection: a case report and systematic review

INTRODUCTION

Intraspinal cerebrospinal fluid (CSF) collection has been reported as a rare cause of lower motor neuron (LMN) disorder. We report a case of bibrachial diplegia associated with intraspinal CSF collection and perform a systematic literature review.

PATIENT AND METHODS

A 52-year-old man developed a bibrachial amyotrophy over 6 years, confirmed by the presence of cervical subacute neurogenic changes at electromyography (EMG). Brain magnetic resonance imaging (MRI) revealed cerebral siderosis, while spine MRI showed a ventral longitudinal intraspinal fluid collection (VLISFC) from C2 to L2. No CSF leakage was localized at myelography; a conservative treatment was chosen. We searched for all published cases until 30th April 2023 and extrapolated data of 44 patients reported in 27 publications.

RESULTS

We observed a male predominance, a younger disease onset compared to amyotrophic lateral sclerosis, and a quite long disease duration, highlighting a slow disease progression. LMN signs were more frequently bilateral, mostly involving C5-C6 myotomes. Around 61% of patients presented additional symptoms, but only three referred to a history of headache. Accordingly, CSF opening pressure was mostly normal. Spinal MRI revealed the presence of VLISFC and in some cases myelomalacia. EMG patterns displayed both chronic and subacute neurogenic change in the cervical region. The disease course mainly depended on the treatment choice, which was mostly represented by a surgical approach when a specific dural defect was detected by imaging.

CONCLUSION

Bibrachial diplegia due to VLISFC can be a treatable cause of focal amyotrophy and presents some clinical and radiological "red flags" which cannot be missed by a clinical neurologist.

Spontaneous Intracranial Hypotension: Case Report and Update on Diagnosis and Treatment

Spontaneous intracranial hypotension (SIH) is an important cause of daily headaches that occur in young and middle-aged, active persons and is often misdiagnosed, leading to prolonged inactivity and rather high healthcare expenditures. Its diagnosis requires a high degree of clinical suspicion and careful interpretation of imaging studies. We present a case of SIH, which was successfully treated but which posed serious diagnostic challenges, ranging from cerebro-vascular disease and meningitis to granulomatous diseases, and for whom every therapeutic attempt just worsened the patient's condition until we finally reached the correct diagnosis. To raise awareness of this condition, we also present an updated overview of the clinical picture, evaluation, and treatment options for SIH.

Spinal epidural venous engorgement-Potential imaging confounder after diagnostic lumbar puncture

Intracranial hypotension is a result of low Cerebrospinal fluid (CSF) pressure caused by either spontaneous or postoperative leakage. The classic presentation of spontaneous intracranial hypotension is acute orthostatic headache, but the diagnosis can sometimes be challenging as some patients may present with atypical initial presentations including cervical pain as well as cervical radiculopathy secondary to cervical spine venous engorgement. We described a 42-year-old female patient who presented initially with neuropathic pain symptoms as well as weakness involving both lower extremities for which she underwent diagnostic lumbar puncture with concern regarding demyelinating neuropathy. However, subsequently she developed postural headache as well as severe cervical pain which was attributed to cervical epidural venous engorgement in setting of intracranial hypotension based on cervical spine magnetic resonance imaging (MRI) findings. She was managed conservatively, and repeated cervical spine MRI 3 days later showed prominent improvement in the imaging findings. Spinal epidural venous engorgement can occur secondary to intracranial hypotension (mainly post lumbar puncture), and can present clinically with neck pain or even symptoms of radiculopathy. Since the findings can mimic more serious conditions, it is extremely important to consider this condition in the differential diagnosis of an enhancing epidural collection in the cervical spine, particularly when intracranial hypotension is suspected.

Long-term Risks of Persistent Ventral Spinal CSF Leaks in SIH: Superficial Siderosis and Bibrachial Amyotrophy

BACKGROUND AND OBJECTIVES

Superficial siderosis, bibrachial amyotrophy, and spinal cord herniation are unusual but serious long-term sequelae of persistent spontaneous spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH), particularly ventral spinal CSF leaks. However, the risk of developing such sequelae has not been established in this population. We undertook this study to determine the risk of these serious complications of persistent ventral spinal CSF leaks.

METHODS

This cohort study was conducted using data from a prospectively maintained database of patients who meet the modified International Classification of Headache Disorders, 3rd edition criteria for SIH. The patient population consisted of a consecutive group of patients with SIH and persistent ventral spinal CSF leaks who were first seen within 1 year of onset of SIH symptoms and who had at least 1 year of follow-up.

RESULTS

Among 51 patients with SIH and a persistent ventral spinal CSF leak, superficial siderosis developed in 6 patients and bibrachial amyotrophy in 2 patients during 280 patient-years of follow-up. The probability of these complications increased from 0% at 48 months to 4.5% (95% confidence interval [CI] 1.0%-28.0%) at 56 months, 10.5% (95% CI 3.0%-36.4%) at 96 months, 32.7% (95% CI 15.0%-62.8%) at 144 months, and 57.9% (95% CI 30.2%-87.6%) at 192 months. None of the patients developed spinal cord herniation.

DISCUSSION

Among patients with SIH and a persistent ventral spinal CSF leak, the risk of developing serious long-term sequelae is considerable. This study shows that early treatment of a ventral spinal CSF leak offers a unique opportunity to prevent neurologic disability from superficial siderosis and bibrachial amyotrophy.

Compressive cervicothoracic pseudomeningocele as a rare manifestation of idiopathic intrathecal hypotension after past trauma: a review

PURPOSE

Spontaneous intracranial or intrathecal hypotension (SIH) is an underdiagnosed phenomenon predominantly presenting with low cerebrospinal fluid (CSF) pressure and postural headache in the setting of CSF leak. Extrathecal CSF collections causing compression of the spinal cord or nerve roots present an even rarer subset of this disease. We aim to describe this pathology in a comprehensive manner while illustrating with a case of our own.

METHODS

We present a literature review on spinal idiopathic pseudomeningoceles and their neurological implications illustrated with a case of an anterior compressive pseudomeningocele between C2 and D7. Further investigations through a myelography and myelo-CT were able to postulate a CSF leak through a discogenic osteophytic microspur at the level C5-C6.

RESULTS

Spinal manifestations are uncommon in cases of idiopathic or spontaneous CSF leak, occurring in about 6% of patients, but myelopathy and radiculopathy involving all spinal segments do occur. In contrast to the cranial complaints, the spinal manifestations usually are not positional and are caused by mass effect from an extradural CSF collection.

CONCLUSION

The utility of multiple imaging modalities such as dynamic myelography and the use of epidural blood patches and fibrin glue polymers should be explored, and surgery is an option if the symptoms persist despite other measures.

Spinal cerebrospinal fluid leak in the context of pars interarticularis fracture

Background

Spinal cerebrospinal fluid (CSF) leak can lead to intracranial hypotension and is an important differential diagnosis to consider in patients with sudden-onset chronic daily headaches. Pars interarticularis (PI) fracture is a potential rare cause of suspected spinal CSF leak.

Methods

This is a retrospective case series of 6 patients with suspected spinal CSF leak evaluated between January 2016 and September 2019. All patients received a magnetic resonance imaging (MRI) of the brain with and without gadolinium, MRI whole spine and full spine computed tomography (CT) myelogram. Targeted epidural patches with fibrin sealant were performed. Treatment response at return visit (3 months post-patch) was documented.

Results

Six patients (4 females, 2 males) were diagnosed with a suspected spinal CSF leak and PI fracture. Mean age at the time of headache onset was 39 years old, and a range from 32 to 50 years old. Mean time to targeted epidural patches with fibrin sealant was 4.5 years. All 6 patients had PI fractures identified on CT myelogram and received targeted epidural patches with fibrin sealant at the site of the PI fracture. All patients had significant improvement in their headache intensity.

Conclusion

Our study highlights: 1) the importance of PI fracture as a possible culprit of suspected spinal CSF leak in patients with intracranial hypotension; 2) the added benefit of CT imaging for detecting bony abnormalities such as fractures in patients with intracranial hypotension; and 3) the successful treatment of suspected spinal CSF leak when targeting the fracture site.

Spontaneous intracranial hypotension: key features for a frequently misdiagnosed disorder

Spontaneous intracranial hypotension (SIH) is a rare neurological condition caused by low cerebrospinal fluid (CSF) volume, most commonly due to a CSF leak. The most common presenting symptom is an orthostatic headache, but some patients may present with atypical neurological manifestations such as cranial nerve palsies, an altered mental status, and movement disorders, which complicate the clinical diagnosis. Therefore, the diagnosis is based on the combination of clinical signs and symptoms, neuroimaging, and/or a low cerebrospinal fluid pressure. In this review, we describe the wide variety of neurological manifestations and complications seen in patients with SIH as well as the most common features described on imaging studies, including both subjective and objective measurements, in order to lead the clinician to a correct diagnosis. The prompt and correct management of patients with SIH will help prevent the development of life-threatening complications, such as subdural hematomas, cerebral venous thrombosis, and coma, and avoid unnecessary invasive procedures.

A Combination of Magnetic Resonance Imaging Techniques to Localize the Dural Defect in a Case of Superficial Siderosis-A Case Report

Background: Superficial siderosis is a progressively disabling disease caused by recurrent subarachnoid hemorrhage with accumulation of hemosiderin in the surface of the central nervous system. Although a wide variety of conditions may cause superficial siderosis, approximately half of the cases are reported to be associated with a defect in the ventral spinal dura mater, in which case treatment entails surgical repair of the defect. Here, we report a case of superficial siderosis and report on our method to pinpoint the dural defect using a combination of magnetic resonance imaging (MRI) techniques. Methods and Results: A 74-year-old female presented suffering from hearing loss and progressive ataxia over a duration of seven years. A T2-weighted MRI study revealed hypointensity in the superficial areas of the central nervous system, leading to the diagnosis of superficial siderosis, and the presence of a fluid-filled collection in the anterior spinal canal of C7 to T10 suggested that a dural defect was the cause of the repeated hemorrhage. A balanced turbo field echo (BTFE) MRI sequence revealed possible dural defects at T1–T2 and T5–T6, and a dynamic improved motion-sensitized driven-equilibrium steady-state free precession (dynamic iMSDE SSFP) sequence revealed an irregular flow of cerebrospinal fluid through the dura at the T5–T6 level. The dural defect was confirmed and sutured through a minimal T5–T6 laminectomy without neurological consequences, and the patient reported mild improvement in gait one year after surgery. Conclusions: A combination of MRI sequences provided the necessary information to confidently perform minimal surgery to repair the dural defect. We recommend coupling a balanced steady-state free precession (SSFP) sequence to provide high resolution, high contrast images of anatomical structures and a dynamic iMSDE SSFP sequence to confirm cerebrospinal fluid motion through the defect.

Chest Pain as a Manifestation of Intracranial Hypotension: Report of Four Cases

BACKGROUND

Chest pain has not been recognized as a manifestation of intracranial hypotension secondary to cerebrospinal fluid leakage.

CASE REPORT

We report on 4 patients with intracranial hypotension diagnosed by the pattern of headaches, temporal proximity to dural puncture, magnetic resonance imaging findings, and resolution of symptoms after epidural blood patch who presented with chest pain. The chest pain was episodic, located in the sternal and interscapular region for the first 3 patients, with no radiation to any other region and no clear relationship to exertion. The fourth patient had episodic chest pain located in the subclavicular and suprascapular region. Two patients reported dyspnea with chest pain. Underlying coronary artery ischemia was excluded using a combination of the electrocardiogram and cardiac enzyme assays. The pain resolved after epidural blood patch treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of chest pain that can be seen with intracranial hypotension and cerebrospinal leakage to ensure appropriate diagnostic tests and treatment.

Spontaneous intracranial hypotension: two steroid-responsive cases

Purpose

Spontaneous intracranial hypotension (SIH) is characterised by orthostatic headache, low cerebrospinal fluid pressure and diffuse pachymeningeal enhancement after intravenous gadolinium contrast administration. Magnetic resonance imaging (MRI) often plays a crucial role for correct diagnosis.

Case description

We described two similar cases of SIH, whose clinical and imaging features are typical for this pathology. At MRI brain scan, both patients showed diffuse and intense pachymeningeal enhancement and moderate venous distension and epidural vein engorgement. The two patients were treated with bed rest and oral steroid therapy, with complete and long-lasting symptomatic relief.

Conclusions

Orthostatic nature of headache is the most indicative clinical feature suggesting SIH; contrast-enhanced MRI provides definite imaging diagnostic findings. Conservative treatment coupled to steroid therapy is often sufficient to obtain complete disappearance of symptoms.

Spine Surgery Complicated by an Engorged Lumbar Epidural Venous Plexus from Cerebrospinal Fluid Overshunting: A Case Report and Review of the Literature

BACKGROUND

Overshunting of cerebrospinal fluid may lead to intracranial hypotension and dilation of spinal epidural veins. Radiculopathy may rarely occur secondary to engorged spinal epidural veins. In addition, the cause of radiculopathy may be obscured by concomitant spinal degenerative changes. We present a case and review the pathogenesis as well as the current clinical literature.

CASE DESCRIPTION

A 29-year-old woman presented with positional headaches from intracranial hypotension in the setting of cerebrospinal fluid overshunting. The patient also had back pain and lumbar radiculopathy, which became more severe after lumboperitoneal shunt placement. On radiographic work-up, there was evidence of right L5 nerve root impingement secondary to a disc bulge and an engorged lumbar epidural venous plexus secondary to overshunting. The patient underwent surgery for a planned L4-5 decompression with a transforaminal lumbar interbody fusion. The operation was complicated by rapid blood loss originating from the epidural venous plexus, and we were unable to safely place the interbody graft.

CONCLUSIONS

Spinal surgeons need to be aware of the rare diagnosis of radiculopathy secondary to epidural venous plexus engorgement, as it may change the treatment approach or lead to deleterious intraoperative consequences, such as hemorrhage.

Impaired cerebrospinal fluid pressure

Abnormalities of cerebrospinal fluid (CSF) pressure are relatively common and may lead to a variety of symptoms, with headache usually being the most prominent one. The clinical presentation of alterations in CSF pressure may vary significantly and show a striking similitude to several primary headache syndromes. While an increase in CSF pressure may be of primary or secondary origin, a pathologic decrease of CSF pressure is usually the result of a meningeal rupture with a resulting leakage of CSF. The pathophysiologic mechanisms of idiopathic intracranial hypertension (IIH) remain largely unknown. However recent evidence indicates that an abnormality in CSF outflow and absorption is likely to play a significant role. Treatment usually consists of a combination of weight loss and a pharmacologic approach using carbonic anhydrase inhibitors. Recent results of the first randomized, double-blind, placebo-controlled trial (RCT) with acetazolamide proved its efficacy in reducing headache and visual disturbances. Clinical evidence suggests efficacy for topiramate and furosemide but no RCT has been conducted to date to confirm these results. In contrast to IIH, spontaneous intracranial hypotension frequently remits spontaneously without specific treatment. If necessary, treatment options range from conservative methods to epidural blood or fibrin sealant patches and surgical interventions.

Dinosaur Tail Sign: A Useful Spinal MRI Finding Indicative of Cerebrospinal Fluid Leakage

OBJECTIVE

To evaluate the imaging characteristics and diagnostic utility of the "Dinosaur tail sign" in the diagnosis of cerebrospinal fluid (CSF) leakage.

BACKGROUND

The authors propose the "Dinosaur tail sign," defined as a combination of the dorsal epidural hyperintensities, fat tissue, spinal cord, and cauda equine on lumbosacral sagittal fat-suppressed T2-weighted image (FST2WI), as a sensitive indicator for diagnosing CSF leakage.

METHODS

Imaging characteristics of the "Dinosaur tail sign" was evaluated in seven spontaneous intracranial hypotension (SIH) and 23 iatrogenic CSF leakage (ICSFL) patients. Additionally, the diagnostic index was compared between the "Dinosaur tail sign" and other previously reported useful magnetic resonance imaging (MRI) and magnetic resonance myelography (MRM) findings.

RESULTS

In contrast to other imaging findings including the epidural expansion, floating dural sac sign, and distension of the spinal epidural veins on MRI, and paraspinal fluid collections (PFC) on MRM, the "Dinosaur tail sign" was found equally in both SIH and ICSFL patients (6 SIH and 19 ICSFL; 83% of all patients with CSF leakage). The "Dinosaur tail sign" showed sufficient diagnostic utility (sensitivity 83%, specificity 94%, accuracy 89%) that was comparable to that of PFC.

CONCLUSION

The "Dinosaur tail sign" is a useful imaging finding suggestive of CSF leakage. Evaluation of subtle interspinous arched hyperintensities on spinal MRI is mandatory for the diagnosis of SIH and ICSFL.

Intraspinal hypotension syndrome presents as transient quadriplegia

Intracranial hypotension can be a complication of epidural anaesthesia. Pure clinical spinal hypotension manifesting as acute transient quadriplegia following epidural anaesthesia is a severe, life-threatening complication that have not been described before. This complication can be solved with an epidural blood patch; thus, it should be familiar to doctors across all specialities.

Diffuse non-aneurysmal SAH in spontaneous intracranial hypotension: Sequela of ventral CSF leak?

Background

Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak has become a well-recognized cause of headaches. Recently, various unusual neurological syndromes have been described in such patients with chronic ventral CSF leaks, including superficial siderosis and an amyotrophic lateral sclerosis-like syndrome. The authors now report two patients with spontaneous intracranial hypotension due to a chronic ventral CSF leak who suffered a diffuse non-aneurysmal subarachnoid hemorrhage (SAH).

Description of cases

A 62-year-old woman underwent uneventful microsurgical repair of a ventral thoracic CSF leak that had been present for 13 years. Seventeen months after surgery, she was found unresponsive and CT showed a diffuse intracranial SAH. Cerebral angiography and spine and brain MRI did not reveal a source of the SAH. A 73-year-old woman was found unresponsive and CT showed a diffuse intracranial SAH. Cerebral angiography and brain MRI did not reveal a source of the SAH, although superficial siderosis was detected. Spine MRI showed a ventral thoracic CSF leak that by history had been present for 41 years. She underwent uneventful microsurgical repair of the CSF leak.

Discussion

The authors suggest that patients with a ventral spinal CSF leak of long duration may be at risk of diffuse non-aneurysmal SAH.

Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy

PURPOSE OF REVIEW

To illustrate clinical presentations, imaging findings, and diagnostic and therapeutic approaches associated with various conditions of intracranial hypotension.

RECENT FINDINGS

Intracranial hypotension occurs spontaneously, following (lumbar) dural puncture, accidental dural opening, or excessive surgical cerebrospinal fluid drainage. The typical clinical manifestation - orthostatic headache - may be masqueraded by atypical clinical findings, including coma, frontotemporal dementia, leptomeningeal hemosiderosis-associated symptoms, and others. MRI signs are highly specific, but the imaging strategy to search for spinal cerebrospinal fluid leaks (none, computed tomography myelography, magnetic resonance myelography with gadolinium, digital subtraction myelography) is a matter of debate. The same is true for the mode of treatment (bed rest, blind, fluoroscopy or computed tomography-guided epidural blood patching, fibrin patching, surgery).

SUMMARY

Clinical presentation as well as diagnostic and therapeutic approaches in intracranial hypotension are very heterogenous.

Update on intracranial hypertension and hypotension

PURPOSE OF REVIEW

The aim of this article is to review recent findings on the pathophysiology of idiopathic changes in intracranial pressure. The review will focus on idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH).

RECENT FINDINGS

Substantial evidence indicates that IIH is associated with delayed absorption of cerebrospinal fluid (CSF). Stenoses of the transverse sinus are common in IIH, but their clinical significance has not been entirely clarified. Despite the observed efficacy of endovascular treatment in some IIH patients, a correlation between the extent of observed stenoses and the clinical course of the disease could not be demonstrated. The underlying cause of SIH is a spontaneous CSF leakage into the epidural space. Conservative treatment and the epidural blood patch remain the treatment of choice for this rare syndrome.

SUMMARY

Recent clinical evidence indicates that IIH is probably a result of CSF outflow abnormality rather than of CSF production. Further research is needed to elucidate the causes of elevated intracranial pressure and the mechanism leading to visual loss. Prospective randomized clinical trials are needed to clarify a possible therapeutic potential of endovascular treatment. Research efforts on SIH should focus further on associated connective tissue disorders predisposing to CSF leaks.