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Madhavan AA, Brinjikji W, Cutsforth-Gregory JK, Amrhein TJ, Kranz PG, Benson JC, Diehn FE, Johnson-Tesch BA, Liebo GB, Lehman VT, Mark IT, Morris PP, Oien MP, Shlapak DP, Verdoorn JT. Myelographic Techniques for the Localization of CSF-Venous Fistulas: Updates in 2024. AJNR Am J Neuroradiol 2024:ajnr.A8299. [PMID: 39089875 DOI: 10.3174/ajnr.a8299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 08/04/2024]
Abstract
CSF-venous fistulas (CVFs) are a common cause of spontaneous intracranial hypotension. Despite their relatively frequent occurrence, they can be exceedingly difficult to detect on imaging. Since the initial description of CVFs in 2014, the recognition and diagnosis of this type of CSF leak has continually increased. As a result of multi-institutional efforts, a wide spectrum of imaging modalities and specialized techniques for CVF detection is now available. It is important for radiologists to be familiar with the multitude of available techniques, because each has unique advantages and drawbacks. In this article, we review the spectrum of imaging modalities available for the detection of CVFs, explain the advantages and disadvantages of each, provide typical imaging examples, and discuss provocative maneuvers that may improve the conspicuity of CVFs. Discussed modalities include conventional CT myelography, dynamic myelography, digital subtraction myelography, conebeam CT myelography, decubitus CT myelography by using conventional energy-integrating detector scanners, decubitus photon counting CT myelography, and intrathecal gadolinium MR myelography. Additional topics to be discussed include optimal patient positioning, respiratory techniques, and intrathecal pressure augmentation.
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Affiliation(s)
- Ajay A Madhavan
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Waleed Brinjikji
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | | | - Timothy J Amrhein
- Division of Neuroradiology, Department of Radiology (T.J.A., P.G.K.), Duke Health, Durham, North Carolina
| | - Peter G Kranz
- Division of Neuroradiology, Department of Radiology (T.J.A., P.G.K.), Duke Health, Durham, North Carolina
| | - John C Benson
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Felix E Diehn
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ben A Johnson-Tesch
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Greta B Liebo
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Vance T Lehman
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ian T Mark
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Pearse P Morris
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Michael P Oien
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Darya P Shlapak
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Jared T Verdoorn
- From the Division of Neuroradiology, Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., B.A.J.-T., G.L., V.T.L., I.T.M., P.P.M., M.P.O., D.P.S., J.T.V.), Mayo Clinic, Rochester, Minnesota
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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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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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Sperre A, Karsrud I, Rodum AHS, Lashkarivand A, Valnes LM, Ringstad G, Eide PK. Prospective Safety Study of Intrathecal Gadobutrol in Different Doses. AJNR Am J Neuroradiol 2023; 44:511-516. [PMID: 37024308 PMCID: PMC10171383 DOI: 10.3174/ajnr.a7841] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/07/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND AND PURPOSE In our clinical practice, we increasingly use intrathecal contrast-enhanced glymphatic MR imaging to assess CSF disturbances. However, because intrathecal MR imaging contrast agents such as gadobutrol (Gadovist; 1.0 mmol/mL) are used off-label, a thorough understanding of the safety profile is required. MATERIALS AND METHODS We performed a prospective safety study from August 2020 to June 2022 of intrathecal gadobutrol, including consecutive patients who received either 0.50, 0.25, or 0.10 mmol. Serious and nonserious adverse events were recorded systematically at 1-3 days, 4 weeks, and >6 months after the intrathecal administration. RESULTS The study included 196 patients who received intrathecal gadobutrol, including patients assessed for idiopathic normal pressure hydrocephalus (iNPH, n = 144) or patients examined for other CSF disorders (non-iNPH cohort; n = 52). The intrathecal gadobutrol doses were either 0.50 mmol (n = 56), 0.25 mmol (n = 111), or 0.10 mmol (n = 29). No serious adverse events were observed. Nonserious adverse events on days 1-3 after intrathecal gadobutrol were, to some degree, dose-dependent but mild-to-moderate, including severe headache, nausea, and/or dizziness in 6/196 (6.3%) patients, and they were more common in the non-iNPH than in the iNPH cohort. At 4 weeks, none reported severe nonserious adverse events, and 9/179 (5.0%) patients had mild-to-moderate symptoms. After >6 months, 2 patients reported mild headache. CONCLUSIONS The present study adds to the accumulating evidence that intrathecal gadobutrol in doses up to 0.50 is safe.
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Affiliation(s)
- A Sperre
- From the Departments of Neurosurgery (A.S., I.K., A.H.S.R., A.L., L.M.V., P.K.E.)
| | - I Karsrud
- From the Departments of Neurosurgery (A.S., I.K., A.H.S.R., A.L., L.M.V., P.K.E.)
| | - A H S Rodum
- From the Departments of Neurosurgery (A.S., I.K., A.H.S.R., A.L., L.M.V., P.K.E.)
| | - A Lashkarivand
- From the Departments of Neurosurgery (A.S., I.K., A.H.S.R., A.L., L.M.V., P.K.E.)
- Institute of Clinical Medicine (A.L., P.K.E.), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - L M Valnes
- From the Departments of Neurosurgery (A.S., I.K., A.H.S.R., A.L., L.M.V., P.K.E.)
| | - G Ringstad
- Department of Radiology and Nuclear Medicine (G.R.)
- Department of Geriatrics and Internal Medicine (G.R.), Sorlandet Hospital, Arendal, Norway
| | - P K Eide
- From the Departments of Neurosurgery (A.S., I.K., A.H.S.R., A.L., L.M.V., P.K.E.)
- Institute of Clinical Medicine (A.L., P.K.E.), Faculty of Medicine, University of Oslo, Oslo, Norway
- Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet, Oslo, Norway
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Neuroimaging in the diagnosis and treatment of intracranial pressure disorders. Neurol Sci 2023; 44:845-858. [PMID: 36333629 DOI: 10.1007/s10072-022-06478-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To review the clinical features, proposed pathophysiology, and the role of medical imaging in the diagnosis and treatment of idiopathic intracranial hypertension and spontaneous intracranial hypotension. METHODS The authors conducted a narrative review of the current literature on intracranial hypertension and hypotension syndromes, with a focus on imaging findings and role of neurointerventional radiology as a therapeutic option for these pathologies. RESULTS Idiopathic intracranial hypertension commonly presents in obese women of childbearing age, being headache and papilledema the main clinical manifestations. Characteristic radiological findings consist of increased cerebrospinal fluid around the optic nerve, partially empty sella turcica and stenosis of the transverse sinuses. Transverse sinus stenting is a treatment alternative that has proven valuable utility in the recent years. Spontaneous intracranial hypotension in most of cases presents with orthostatic headache and has predilection for female population. The typical radiological features in the brain consist of subdural fluid collections, enhancement of the dura, engorgement of the venous structures, pituitary enlargement, and sagging of the brain. In this pathology, a cerebrospinal fluid leak in the spine associated with a defect in the dura, meningeal diverticulum, or a cerebrospinal fluid-venous leak must be actively ruled out. CONCLUSIONS Neurologic complaints secondary to changes in intracranial pressure exhibit certain clinical features that in combination with fairly specific radiological patterns allow a highly accurate diagnosis. The diverse specialists in neurosciences should be aware of the multiple image modalities in the study of these syndromes as well as the treatment alternatives by neurointerventional radiology.
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Choi SY, Seong M, Kim EY, Youn MS, Cho S, Jang H, Lee MJ. Outcome of epidural blood patch for imaging-negative spontaneous intracranial hypotension. Cephalalgia 2023; 43:3331024221140471. [PMID: 36739515 DOI: 10.1177/03331024221140471] [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: 02/06/2023]
Abstract
BACKGROUND Spontaneous intracranial hypotension is diagnosed by an abnormal finding in brain MRI, spinal imaging, or lumbar puncture. However, the sensitivity of each test is low. We investigated whether patients with suspected spontaneous intracranial hypotension and negative imaging findings would respond to epidural blood patch. METHODS We prospectively recruited patients with new-onset orthostatic headache admitted at the Samsung Medical Center from January 2017 to July 2021. In patients without abnormal imaging findings and no history of prior epidural blood patch, treatment outcome-defined as both 50% response in maximal headache intensity and improvement of orthostatic component-was collected at discharge and three months after epidural blood patch. RESULTS We included 21 treatment-naïve patients with orthostatic headache and negative brain and spinal imaging results who received epidural blood patch. After epidural blood patch (mean 1.3 times, range 1-3), 14 (66.7%) and 19 (90.5%) patients achieved both 50% response and improvement of orthostatic component at discharge and three months post-treatment, respectively. Additionally, complete remission was reported in 11 (52.4%) patients at three-month follow-up, while most of the remaining patients had only mild headaches. Among nine (42.9%) patients who underwent lumbar puncture, none had an abnormally low opening pressure (median 13.8 cm H2O, range 9.2-21.5). CONCLUSION Given the high responder rates of epidural blood patch in our study, empirical epidural blood patch should be considered to treat new-onset orthostatic headache, even when brain and spinal imaging are negative. The necessity of lumbar puncture is questionable considering the high response rate of epidural blood patch and low rate of "low pressure."
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Affiliation(s)
- So Youn Choi
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Minjung Seong
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eung Yeop Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Michelle Sojung Youn
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Hyemin Jang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Alzheimer's Disease Convergence Research Center, Samsung Medical Center, Seoul, South Korea
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Fedin AI. [The glymphatic system in the brain - neurobiology and clinical pathology]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:13-19. [PMID: 37315237 DOI: 10.17116/jnevro202312305113] [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: 06/16/2023]
Abstract
Given new information about the neurobiology of the processes of removal of waste products of the brain, consisting of the lymphatic vessels into the dura and the glial-lymphatic (glymphatic) system. The role of astrocytes and water-conducting channels located on them in cell membranes formed by the protein aquaporin-4 is emphasized. The connection between the functioning of the glymphatic system and the slow phase of sleep is discussed. Possible mechanisms for the development of cognitive impairments in violation of the function of the glymphatic system and a delay in the elimination of β-amyloid are shown. Directions of pathogenetic therapy are given.
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Affiliation(s)
- A I Fedin
- Pirogov Russian National Research Medical University, Moscow, Russia
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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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Kohan L, Pellis Z, Provenzano DA, Pearson ACS, Narouze S, Benzon HT. American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement. Reg Anesth Pain Med 2022; 47:511-518. [DOI: 10.1136/rapm-2022-103830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/03/2022] [Indexed: 11/03/2022]
Abstract
The medical field has been experiencing numerous drug shortages in recent years. The most recent shortage to impact the field of interventional pain medicine is that of iodinated contrast medium. Pain physicians must adapt to these changes while maintaining quality of care. This position statement offers guidance on adapting to the shortage.
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Lee SY, Park BY, Ryu T, Lee JH, Kim DH, Roh WS. Linear indices of ventricular volume on brain computed tomography as markers of effectiveness of epidural blood patch for spontaneous intracranial hypotension: A case report. Medicine (Baltimore) 2022; 101:e29279. [PMID: 35960083 PMCID: PMC9371481 DOI: 10.1097/md.0000000000029279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Epidural blood patch (EBP) is an effective treatment for spontaneous intracranial hypotension (SIH). However, its effectiveness can only be judged through subjective symptom improvement; no objective markers have been reported. Linear indices of ventricular volume on brain computed tomography (CT) may aid the objective evaluation of the effectiveness of EBP in patients with SIH. PATIENT CONCERNS A 45-year-old man was hospitalized due to a 3-week history of orthostatic headache, dizziness, and neck pain. He had visited a local emergency department at symptom onset. His neurological examination results were normal and vital signs were stable. DIAGNOSES Brain magnetic resonance imaging (MRI) revealed pachymeningeal enhancement in both convexities with a small subdural hematoma (SDH). Based on the clinical features and MRI findings, he was diagnosed with SIH complicated by SDH. INTERVENTIONS Non-targeted EBP was performed, first at the lumbar level and subsequently at the thoracic level. Linear indices of ventricular volume, including the Evans' index, frontal-occipital horn ratio, and bicaudate index, were measured through brain CT performed before and after EBP. OUTCOMES After lumbar EBP, there was no symptom relief or increase in linear indices of ventricular volume on brain CT. In contrast, the patient's symptoms completely resolved and the linear indices of ventricular volume increased after thoracic EBP. LESSONS The effectiveness of EBP, which is currently evaluated solely based on changes in symptom severity, can be assessed using linear indices of ventricular volume.
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Affiliation(s)
- So Young Lee
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Nam-gu, Daegu, Republic of Korea
| | - Bum Young Park
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Nam-gu, Daegu, Republic of Korea
| | - Taeha Ryu
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Nam-gu, Daegu, Republic of Korea
| | - Ji Hyeon Lee
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Nam-gu, Daegu, Republic of Korea
| | - Dong Hyuck Kim
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Nam-gu, Daegu, Republic of Korea
| | - Woon Seok Roh
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Nam-gu, Daegu, Republic of Korea
- *Correspondence: Woon Seok Roh, Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, 33, Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Republic of Korea (e-mail: )
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Bakhsh A, Elmolla M, Buxton N, Brodbelt A. Chronic CSF leak from lumbar-peritoneal shunt tract: A case report. Surg Neurol Int 2022; 13:205. [PMID: 35673636 PMCID: PMC9168392 DOI: 10.25259/sni_1084_2021] [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: 10/28/2021] [Accepted: 04/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background We describe a case of long-standing intracranial hypotension caused by an iatrogenic arachnoid diverticulum. This case illustrates two learning points. First, excessive CSF absorption may occur through an acquired arachnoid-epidural venous plexus at a dural defect. Second, a long-standing CSF leak may benefit from definitive surgical repair in the first instance. Case Description A 55-year-old female, with known idiopathic intracranial hypertension, presented with disabling chronic low-pressure symptoms after having a lumboperitoneal shunt removed 5 years previously. MRI scan revealed a Chiari I malformation (CMI) and a small dural interruption at the L3/4 space. CT myelography confirmed the abnormality. Intraoperatively, a dural defect and arachnoid bleb with an overlying attachment of adipose tissue and a vessel were found. Postoperatively, the patient has marked resolution of her headaches and dizziness and is mobilizing independently. Conclusion Excessive CSF absorption appears to have occurred through an acquired arachnoid-epidural venous plexus. A high index of suspicion for intracranial hypotension is required in patients with low pressure symptoms and a CMI.
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Affiliation(s)
- Ali Bakhsh
- Department of Neurosurgery, NHS, Liverpool, Merseyside, United Kingdom
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Lashkarivand A, Eide PK. Brain Sagging Dementia -- Diagnosis, Treatment, and Outcome: A Review. Neurology 2022; 98:798-805. [PMID: 35338080 DOI: 10.1212/wnl.0000000000200511] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Brain sagging dementia (BSD), caused by spontaneous intracranial hypotension (SIH), is a rare syndrome that is only recently recognized, mimicking the clinical findings of behavioral variant frontotemporal dementia (bvFTD). Being aware of its signs and symptoms is essential for early diagnosis and treatment in this potentially reversible form of dementia. Our objective was to identify cases with BSD in the literature and present its clinical characteristics, diagnostic workup, treatment options, and outcome.The review was reported according to PRISMA guidelines and registered with the PROSPERO database (CRD42020150709). MEDLINE, EMBASE, PsychINFO, and Cochrane Library were searched. There was no date restriction. The search was updated in April 2021.A total of 983 articles were screened and assessed for eligibility. Twenty-nine articles (25 case reports and four series) and 70 patients were selected for inclusion. No cranial leak cases were identified. BSD diagnosis should be made based on clinical signs and symptoms and radiological findings. There is a male predominance (F: M ratio 1:4) and a peak incidence in the 6th decade of life. The main clinical manifestation is insidious onset, gradually progressive cognitive and behavioral changes characteristic for bvFTD. Headache is present in the majority of patients (89%). The presence of brain sagging and absence of frontotemporal atrophy is an absolute criterion for the diagnosis. The CSF leak is identified with myelography and digital subtraction myelography. The treatment and repair depend on the etiology and extent of the dural defect, although an epidural blood patch is the first-line treatment in most cases. With treatment, 81% experienced partial and 67% complete resolution of their symptoms. This review highlights the most important clinical aspects of BSD. Due to the sparse evidence and lack of BSD awareness, many patients are most likely left undiagnosed. Recognizing this condition is essential to provide early treatment to reverse the cognitive and behavioral changes that may otherwise progress and fully impair the patient. Moreover, patients with longstanding SIH must be carefully assessed for cognitive and behavioral changes.
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Affiliation(s)
- Aslan Lashkarivand
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Konovalov AN, Vinogradov EV, Grebenev FV, Batalov AI, Shevchenko KV, Pronin IN, Konovalov NA. [Spinal CSF-venous fistula: case report and literature review]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:41-49. [PMID: 35758077 DOI: 10.17116/neiro20228603141] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
UNLABELLED Syndrome of spontaneous intracranial hypotension is increasingly described in the literature as a multifactorial disease with impairment of the quality of life and risk of mortality. CSF-venous fistula as a cause of intracranial hypotension syndrome is extremely rare and requires complex diagnosis and timely surgical treatment. OBJECTIVE We present a 55-year-old patient with acute spontaneous intracranial hypotension and spinal CSF-venous fistula. Literature data are also analyzed. RESULTS Algorithm for diagnosis and efficacy of microsurgical resection of CSF-venous fistula is demonstrated. CONCLUSION Intracranial hypotension following spinal fistula requires careful examination. Accurate understanding of pathophysiological and anatomical features of this disease is necessary to select an effective treatment method.
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Affiliation(s)
| | | | | | - A I Batalov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
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14
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Madhavan AA, Carr CM, Benson JC, Brinjikji W, Diehn FE, Kim DK, Lehman VT, Liebo GB, Morris PP, Shlapak DP, Verdoorn JT, Morris JM. Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization. Clin Neuroradiol 2021; 32:537-545. [PMID: 34292360 DOI: 10.1007/s00062-021-01060-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intrathecal gadolinium magnetic resonance (MR) myelography can be used to localize various types of spinal cerebrospinal fluid (CSF) leaks; however, its diagnostic yield is not well known. We sought to determine the diagnostic yield of MR myelography in patients with spontaneous intracranial hypotension. METHODS A retrospective review was performed on all patients who had undergone intrathecal gadolinium MR myelography at our institution from 2002 to 2020 for suspected spinal CSF leak. The MR myelography images were reviewed for the presence or absence of a spinal CSF leak site. Images were also evaluated for the presence an extradural fluid collection. RESULTS A total of 97 patients were included in the final cohort. The average age was 52.6 years; 67.0% were female, 4 patients underwent 2 examinations each, yielding a total of 101 MR myelograms. The source of a spinal CSF leak was localized in 14 patients. The diagnostic yield for CSF leak localization on intrathecal gadolinium MR myelography was 14/101 (13.9%) per GdM examination and 14/97 (14.4%) per patient. Among the subset of patients without extradural fluid collections, the yield was 15.7% per examination. All detected leaks were either CSF-venous fistulas or distal nerve root sleeve tears. CONCLUSION Intrathecal gadolinium MR myelography is capable of localizing CSF-venous fistulas and distal nerve root sleeve tears; however, our data show that it has a limited diagnostic yield. We suggest that other modalities may be a better first step before attempting intrathecal gadolinium MR myelography.
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Affiliation(s)
- Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA.
| | - Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Greta B Liebo
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Pearse P Morris
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Jonathan M Morris
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
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15
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Angelopoulou E, Pantou E, Zacharis G, Rentzos M, Stefanis L, Zouvelou V. Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00109-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Spontaneous intracranial hypotension (SIH) is characterized by positional headache caused by low CSF pressure, without any major traumatic event. Optimal treatment is still debated; epidural blood patch (EBP) is usually used after unsuccessful conservative treatment with variable efficacy and potentially severe complications. Although steroids have been reported to be beneficial, their effectiveness is still controversial, and more clinical evidence is needed.
Case presentation
A 37-year-old woman was admitted to the neurology department due to severe orthostatic headache with nausea over the last 5 days. No trauma history or spinal manipulation were mentioned. On arrival, neurological examination, brain CT, and laboratory investigation were normal. Intracranial hypotension was clinically suspected, and lumbar puncture revealed low opening pressure. Brain MRI demonstrated pachymeningeal gadolinium enhancement and distended and rounded dural venous sinuses, while cervicothoracic spine MRI revealed thoracic CSF leakage, leading to SIH diagnosis. The patient was treated with high-dose intravenous methylprednisolone, with complete clinical resolution within 24 h.
Conclusions
Our case, combined with literature evidence, supports the high-dose intravenous corticosteroids as a reasonable treatment option in selected cases, before trying EBP or surgical repair. Randomized clinical trials are needed, in order to optimize SIH patients’ outcomes.
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Osawa I, Kozawa E, Mitsufuji T, Yamamoto T, Araki N, Inoue K, Niitsu M. Intravenous enhanced 3D FLAIR imaging to identify CSF leaks in spontaneous intracranial hypotension: Comparison with MR myelography. Eur J Radiol Open 2021; 8:100352. [PMID: 34026946 PMCID: PMC8134034 DOI: 10.1016/j.ejro.2021.100352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/27/2021] [Accepted: 05/08/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose To evaluate the clinical utility of intravenous gadolinium-enhanced heavily T2-weighted 3D fluid-attenuated inversion recovery (HT2-FLAIR) imaging for identifying spinal cerebrospinal fluid (CSF) leaks in patients with spontaneous intracranial hypotension (SIH). Methods Patients with SIH underwent MR myelography and post-contrast HT2-FLAIR imaging after an intravenous gadolinium injection. Two types of CSF leaks (epidural fluid collection and CSF leaks around the nerve root sleeve) at each vertebral level were compared between the 2 sequences. The total numbers of CSF leaks and vertebral levels involved were recorded for the whole spine. The sequence that was superior for the overall visualization of epidural and paraspinal fluid collection was then selected. Results Nine patients with SIH were included in the present study. HT2-FLAIR imaging was equivalent or superior to MR myelography at each level for detecting the 2 types of CSF leaks. In the 2 types of CSF leaks, the total numbers of CSF leaks and levels involved were higher on HT2-FLAIR images than on MR myelography, while no significant difference was observed for CSF leaks around the nerve root sleeve. In all 9 patients, HT2-FLAIR imaging was superior to MR myelography for the overall visualization of epidural and paraspinal fluid collection. Conclusion Intravenous gadolinium-enhanced HT2-FLAIR imaging was superior to MR myelography for the visualization of CSF leaks in patients with SIH. This method can be useful for identifying spinal CSF leaks.
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Key Words
- CHESS, Chemical shift selective
- CSF, Cerebrospinal fluid
- FLAIR, Fluid-attenuated inversion recovery
- HT2-FLAIR, Heavily T2-weighted fluid-attenuated inversion recovery
- Heavily T2-weighted 3D FLAIR
- Intravenous gadolinium-enhanced MR imaging
- MIP, Maximum intensity projection
- MPR, Multiplanar reconstruction
- MR myelography
- MRI, Magnetic resonance imaging
- SIH, Spontaneous intracranial hypotension
- Spinal cerebrospinal fluid leak
- Spontaneous intracranial hypotension
- T1W, T1-weighted
- T2W, T2-weighted
- TSE, Turbo spin echo
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Affiliation(s)
- Iichiro Osawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
- Corresponding author at: 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan.
| | - Eito Kozawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Takashi Mitsufuji
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Toshimasa Yamamoto
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Nobuo Araki
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Kaiji Inoue
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Mamoru Niitsu
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
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17
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Kumar N. Superficial Siderosis: A Clinical Review. Ann Neurol 2021; 89:1068-1079. [PMID: 33860558 DOI: 10.1002/ana.26083] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 12/15/2022]
Abstract
Superficial siderosis of the central nervous system results from subpial hemosiderin deposition due to chronic low-grade bleeding into the subarachnoid space. The confluent and marginal subpial hemosiderin is best appreciated on iron-sensitive magnetic resonance imaging sequences. With widespread use of magnetic resonance imaging, the disorder is increasingly being recognized, including in asymptomatic individuals. Gait ataxia, often with hearing impairment is a common clinical presentation. A clinical history of subarachnoid hemorrhage is generally not present. A macrovascular pathology is generally not causative. The most common etiology is dural disease, often dural tears. Prior or less commonly ongoing symptoms of craniospinal hypovolemia may be present. Common etiologies for dural tears include disc disease and trauma, including surgical trauma. Patients with dural tears due to herniated and calcified discs often have a ventral intraspinal fluid collection due to cerebrospinal fluid leak. A precise identification of the dural tear relies on multimodality imaging. It has been speculated that chronic bleeding from fragile blood vessels around the dural tear may be the likely underlying mechanism. Surgical correction of the bleeding source is a logical therapeutic strategy. Clinical outcomes are variable, although neuroimaging evidence of successful dural tear repair is noted. The currently available data regarding use of deferiprone in patients with superficial siderosis is insufficient to recommend its routine use in patients. ANN NEUROL 2021;89:1068-1079.
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Affiliation(s)
- Neeraj Kumar
- Department of Neurology, Mayo Clinic, Rochester, MN
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18
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Kumar N. Diskogenic Dural Defect Is the Reason for the Ventral Location of the Epidural Spinal Fluid Collection Seen in Superficial Siderosis. Neurol Clin Pract 2021; 11:e508-e515. [PMID: 34484949 DOI: 10.1212/cpj.0000000000001085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/19/2021] [Indexed: 12/28/2022]
Abstract
Purpose of Review Superficial siderosis (SS) of the nervous system is often due to a dural pathology. This review focuses on recent developments related to the management of this subgroup of patients with SS. Recent Findings The presence of an epidural ventral spinal fluid collection in patients with SS is a clue to the presence of a diskogenic dural defect. The location of the defect is ascertained by a dynamic CT myelogram, which involves placing the patient in a prone position with hips elevated. This permits gravity-assisted preferential ventral localization of the contrast and active scanning during contrast injection facilitates a precise delineation of the initial point of contrast extravasation which localizes the defect. Summary Diskogenic dural defects are commonly the underlying etiology for SS in patients with a ventral spinal fluid collection. A dynamic CT myelogram facilitates detection and subsequent repair of these defects, which arrests the continued low-grade subarachnoid bleeding.
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Affiliation(s)
- Neeraj Kumar
- Department of Neurology, Mayo Clinic, Rochester, MN
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19
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Yankova G, Bogomyakova O, Tulupov A. The glymphatic system and meningeal lymphatics of the brain: new understanding of brain clearance. Rev Neurosci 2021; 32:693-705. [PMID: 33618444 DOI: 10.1515/revneuro-2020-0106] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/31/2021] [Indexed: 12/25/2022]
Abstract
The glymphatic system and meningeal lymphatics have recently been characterized. Glymphatic system is a glia-dependent system of perivascular channels, and it plays an important role in the removal of interstitial metabolic waste products. The meningeal lymphatics may be a key drainage route for cerebrospinal fluid into the peripheral blood, may contribute to inflammatory reaction and central nervous system (CNS) immune surveillance. Breakdowns and dysfunction of the glymphatic system and meningeal lymphatics play a crucial role in age-related brain changes, the pathogenesis of neurovascular and neurodegenerative diseases, as well as in brain injuries and tumors. This review discusses the relationship recently characterized meningeal lymphatic vessels with the glymphatic system, which provides perfusion of the CNS with cerebrospinal and interstitial fluids. The review also presents the results of human studies concerning both the presence of meningeal lymphatics and the glymphatic system. A new understanding of how aging, medications, sleep and wake cycles, genetic predisposition, and even body posture affect the brain drainage system has not only changed the idea of brain fluid circulation but has also contributed to an understanding of the pathology and mechanisms of neurodegenerative diseases.
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Affiliation(s)
- Galina Yankova
- Lavrentyev Institute of Hydrodynamics, Siberian Branch, Russian Academy of Sciences, Novosibirsk630090, Russia.,Novosibirsk State University, Novosibirsk630090,Russia
| | - Olga Bogomyakova
- International Tomography Center, Siberian Branch, Russian Academy of Sciences, Novosibirsk630090, Russia
| | - Andrey Tulupov
- Novosibirsk State University, Novosibirsk630090,Russia.,International Tomography Center, Siberian Branch, Russian Academy of Sciences, Novosibirsk630090, Russia.,Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Novosibirsk 630055, Russia
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20
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Abstract
PURPOSE OF REVIEW To provide an update on recent developments in the understanding, diagnosis, and treatment of CSF-venous fistula (CVF). RECENT FINDING CVF is a recently recognized cause of spontaneous intracranial hypotension (SIH), an important secondary headache, in which an aberrant connection is formed between the spinal subarachnoid space and an adjacent spinal epidural vein permitting unregulated loss of CSF into the circulatory system. CVFs often occur without a concurrent epidural fluid collection; therefore, CVF should be considered as a potential etiology for patients with SIH symptomatology but without an identifiable CSF leak. Imaging plays a critical role in the detection and localization of CVFs, with a number of imaging techniques and provocative maneuvers described in the literature to facilitate their localization for targeted and definitive treatment. Increasing awareness and improving the localization of CVFs can allow for improved outcomes in the SIH patient population. Future prospective studies are needed to determine the diagnostic performance of currently available imaging techniques as well as their ability to inform workup and guide treatment decisions.
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Affiliation(s)
- Michelle Roytman
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Gayle Salama
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Matthew S Robbins
- Department of Neurology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - J Levi Chazen
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA.
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21
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Johnson DR, Carr CM, Luetmer PH, Diehn FE, Lehman VT, Cutsforth-Gregory JK, Verdoorn JT, Krecke KN. Diffuse Calvarial Hyperostosis in Patients with Spontaneous Intracranial Hypotension. World Neurosurg 2020; 146:e848-e853. [PMID: 33220476 DOI: 10.1016/j.wneu.2020.11.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Diagnosis of spontaneous intracranial hypotension (SIH) may be delayed due to nonspecific symptoms and variable imaging findings. Cases of hyperostosis in children who are overshunted, a process that may be physiologically analogous to adults with SIH, have been reported by others and observed in our practice. The purpose of this retrospective study was to assess the frequency and pattern of calvarial hyperostosis in patients with SIH. METHODS We retrospectively reviewed computed tomography and magnetic resonance imaging examinations from consecutive patients who underwent myelography for the evaluation of SIH to assess for the presence of generalized calvarial thickening or development of a secondary layer of bone. Patients with typical benign hyperostosis frontalis were excluded. Patient demographics and clinical factors were evaluated for association with hyperostosis. RESULTS Among 285 patients with SIH, 40 (14.0%) demonstrated diffuse calvarial hyperostosis on imaging. Most of these patients (32/40; 80.0%) demonstrated a distinct circumferentially layered appearance to the skull, whereas 8 of 40 (20.0%) had generalized calvarial thickening without layering. CONCLUSIONS Diffuse calvarial hyperostosis, particularly the concentrically layered form that we term "layer cake skull," is a relatively common imaging feature in patients with SIH. In the appropriate clinical context, this finding will allow the possibility of SIH to be raised based on computed tomography imaging, which is otherwise of limited utility in the initial diagnosis of this condition.
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Affiliation(s)
- Derek R Johnson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Carrie M Carr
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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22
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Higgins JN, Axon PR, Macfarlane R. Spontaneous Intracranial Hypotension Complicated by Subdural Effusions Treated by Surgical Relief of Cranial Venous Outflow Obstruction. J Neurol Surg Rep 2020; 81:e59-e65. [PMID: 33403194 PMCID: PMC7775190 DOI: 10.1055/s-0040-1722268] [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: 07/10/2020] [Accepted: 10/28/2020] [Indexed: 12/03/2022] Open
Abstract
Spontaneous intracranial hypotension describes the clinical syndrome brought on by a cerebrospinal fluid (CSF) leak. Orthostatic headache is the key symptom, but others include nausea, vomiting, and dizziness, as well as cognitive and mood disturbance. In severe cases, the brain slumps inside the cranium and subdural collections develop to replace lost CSF volume. Initial treatment is by bed rest, but when conservative measures fail, attention is focused on finding and plugging the leak, although this can be very difficult and some patients remain bedbound for months or years. Recently, we have proposed an alternative approach in which obstruction to cranial venous outflow would be regarded as the driving force behind a chronic elevation of CSF pressure, which eventually causes dural rupture. Instead of focusing on the site of rupture, therefore, investigation and treatment can be directed at locating and relieving the obstructing venous lesion, allowing intracranial pressure to fall, and the dural defect to heal. The case we describe illustrates this idea. Moreover, since there was a graded clinical response to successive interventions relieving venous obstruction, and eventual complete resolution, it also provides an opportunity to consider particular symptoms in relation to cerebral venous insufficiency in its own right.
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Affiliation(s)
- J Nicholas Higgins
- Department of Radiology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Patrick R. Axon
- Cambridge Skull Base Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Robert Macfarlane
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
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23
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Pope MC, Carr CM, Brinjikji W, Kim DK. Safety of Consecutive Bilateral Decubitus Digital Subtraction Myelography in Patients with Spontaneous Intracranial Hypotension and Occult CSF Leak. AJNR Am J Neuroradiol 2020; 41:1953-1957. [PMID: 32883671 DOI: 10.3174/ajnr.a6765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/01/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Digital subtraction myelography performed with the patient in the lateral decubitus position has the potential for increased sensitivity over prone-position myelography in the detection of spinal CSF-venous fistulas, a well-established cause of spontaneous intracranial hypotension. We report on the safety of performing routine, consecutive-day right and left lateral decubitus digital subtraction myelography in these patients. MATERIALS AND METHODS In this retrospective case series, all patients undergoing consecutive-day lateral decubitus digital subtraction myelography for suspected spinal CSF leak between September 2018 and September 2019 were identified. Chart review was performed to identify any immediate or delayed adverse effects associated with the procedures. Procedural parameters were also analyzed due to inherent variations associated with the positive-pressure myelography technique that was used. RESULTS A total of 60 patients underwent 68 pairs of consecutive-day lateral decubitus digital subtraction myelographic examinations during the study period. No major adverse effects were recorded. Various minor adverse effects were observed, including pain requiring analgesics (27.2%), nausea/vomiting requiring antiemetics (8.1%), and transient neurologic effects such as syncope, vertigo, altered mental status, and autonomic dysfunction (5.1%). Minor transient neurologic effects were correlated with increasing volumes of intrathecal saline injectate used for thecal sac prepressurization. CONCLUSIONS In patients with spontaneous intracranial hypotension and suspected spontaneous spinal CSF leak, consecutive-day lateral decubitus digital subtraction myelography demonstrates an acceptable risk profile without evidence of neurotoxic effects from cumulative intrathecal contrast doses. Higher intrathecal saline injectate volumes may correlate with an increased incidence of minor transient periprocedural neurologic effects.
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Affiliation(s)
- M C Pope
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - C M Carr
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - W Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - D K Kim
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
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24
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Halvorsen M, Edeklev CS, Fraser-Green J, Løvland G, Vatnehol SAS, Gjertsen Ø, Nedregaard B, Sletteberg R, Ringstad G, Eide PK. Off-label intrathecal use of gadobutrol: safety study and comparison of administration protocols. Neuroradiology 2020; 63:51-61. [PMID: 32803338 PMCID: PMC7803712 DOI: 10.1007/s00234-020-02519-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/08/2020] [Indexed: 12/23/2022]
Abstract
Purpose Magnetic resonance imaging (MRI) contrast agents have been used off-label for diagnosis of cerebrospinal fluid (CSF) leaks and lately also for assessment of the glymphatic system and meningeal lymphatic drainage. The purpose of this study was to further evaluate the short- and long-term safety profile of intrathecal MRI contrast agents. Methods In this prospective study, we compared the safety profile of different administration protocols of intrathecal gadobutrol (GadovistTM; 1.0 mmol/ml). Gadobutrol was administered intrathecal in a dose of 0.5 mmol, with or without iodixanol (VisipaqueTM 270 mg I/ml; 3 ml). In addition, a subgroup was given intrathecal gadobutrol in a dose of 0.25 mmol. Adverse events were assessed at 1 to 3 days, 4 weeks, and after 12 months. Results Among the 149 patients, no serious adverse events were seen in patients without history of prior adverse events. The combination of gadobutrol with iodixanol did not increase the occurrence of non-serious adverse events after days 1–3. Intrathecal gadobutrol in a dose of 0.25 mmol caused less severity of nausea, as compared with the dose of 0.5 mmol. The clinical diagnosis was the major determinant for occurrence of non-serious adverse events after intrathecal gadobutrol. Conclusion This prospective study showed that intrathecal administration of gadobutrol in a dose of 0.5 mmol is safe. Non-serious adverse events were to a lesser degree affected by the administration protocols, though preliminary data are given that side effects of intrathecal gadobutrol are dose-dependent.
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Affiliation(s)
- Merete Halvorsen
- Department. of Neurosurgery, Oslo University Hospital - Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway
| | - Camilla Sæthre Edeklev
- Department. of Neurosurgery, Oslo University Hospital - Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway
| | - Jorunn Fraser-Green
- The Interventional Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Grethe Løvland
- The Interventional Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | | | - Øivind Gjertsen
- Dept. of Radiology and Nuclear Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Bård Nedregaard
- Dept. of Radiology and Nuclear Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Ruth Sletteberg
- Dept. of Radiology and Nuclear Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Geir Ringstad
- Dept. of Radiology and Nuclear Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Per Kristian Eide
- Department. of Neurosurgery, Oslo University Hospital - Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway. .,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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Patel M, Atyani A, Salameh JP, McInnes M, Chakraborty S. Safety of Intrathecal Administration of Gadolinium-based Contrast Agents: A Systematic Review and Meta-Analysis. Radiology 2020; 297:75-83. [PMID: 32720867 DOI: 10.1148/radiol.2020191373] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background The use of MR cisternography with intrathecal administration of gadolinium-based contrast agents (GBCAs) is limited by a lack of understanding of the relationship between intrathecal GBCA exposure and dose-related adverse events. Purpose To perform a systematic review to establish an understanding of the dose-response relationship of intrathecal GBCAs and to characterize related adverse events, particularly at higher doses. Materials and Methods Medline, Embase, CINAHL, and Central databases were searched for studies reporting intrathecal GBCA use. Data extraction included studies focused on rates and types of adverse events after intrathecal GBCA exposure. A two-tailed independent sample t test statistic was used to evaluate the relationship between GBCA dose and the presence of serious versus nonserious adverse events. Meta-analysis was used to determine the overall incidence of adverse events. Study quality and publication bias were assessed using the modified Newcastle-Ottawa scale and a funnel plot (effect size measured using Hedges' g followed by the Egger test), respectively. Results Fifty-three studies with a total of 1036 patients were included for analysis. The overall rate of adverse events after intrathecal administration of GBCA was 13% (95% confidence interval [CI]: 9.3%, 18%). Meta-analysis revealed moderate heterogeneity (I2 = 62%). Serious adverse event rates could not be determined with meta-analysis. They were reported in 10 studies and were primarily neurologic in nature, with two cases of coma-one resulting in death. Serious adverse events were associated with significantly higher GBCA doses when compared with nonserious adverse events (mean difference, 4.5 mmol; 95% CI: 2.3 mmol, 6.6 mmol; P = .008). For serious adverse events, there was no clear dose-dependent increase in severity above 2.0 mmol. Conclusion Overall, intrathecal administration of GBCAs at doses greater than 1.0 mmol are associated with serious neurotoxic complications with relative clinical safety at lower doses. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Kanal in this issue.
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Affiliation(s)
- Mihilkumar Patel
- From the Department of Medical Imaging, Division of Neuroradiology, University of Ottawa, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9
| | - Almohannad Atyani
- From the Department of Medical Imaging, Division of Neuroradiology, University of Ottawa, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9
| | - Jean-Paul Salameh
- From the Department of Medical Imaging, Division of Neuroradiology, University of Ottawa, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9
| | - Matthew McInnes
- From the Department of Medical Imaging, Division of Neuroradiology, University of Ottawa, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9
| | - Santanu Chakraborty
- From the Department of Medical Imaging, Division of Neuroradiology, University of Ottawa, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9
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Dobrocky T, Winklehner A, Breiding PS, Grunder L, Peschi G, Häni L, Mosimann PJ, Branca M, Kaesmacher J, Mordasini P, Raabe A, Ulrich CT, Beck J, Gralla J, Piechowiak EI. Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences. AJNR Am J Neuroradiol 2020; 41:1309-1315. [PMID: 32554417 DOI: 10.3174/ajnr.a6592] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/06/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spine MR imaging plays a pivotal role in the diagnostic work-up of spontaneous intracranial hypotension. The aim of this study was to compare the diagnostic accuracy of unenhanced spine MR imaging and intrathecal gadolinium-enhanced spine MR imaging for identification and localization of CSF leaks in patients with spontaneous intracranial hypotension. MATERIALS AND METHODS A retrospective study of patients with spontaneous intracranial hypotension examined from February 2013 to October 2017 was conducted. Their spine MR imaging was reviewed by 3 blinded readers for the presence of epidural CSF using 3 different sequences (T2WI, 3D T2WI fat-saturated, T1WI gadolinium). In patients with leaks, the presumed level of the leak was reported. RESULTS In total, 103 patients with spontaneous intracranial hypotension (63/103 [61%] women; mean age, 50 years) were evaluated. Seventy had a confirmed CSF leak (57/70 [81%] proved intraoperatively), and 33 showed no epidural CSF on multimodal imaging. Intrathecal gadolinium-enhanced spine MR imaging was nonsuperior to unenhanced spine MR imaging for the detection of epidural CSF (P = .24 and .97). All MR imaging sequences had a low accuracy for leak localization. In all patients, only 1 leakage point was present, albeit multiple suspicious lesions were reported in all sequences (mean, 5.0). CONCLUSIONS Intrathecal gadolinium-enhanced spine MR imaging does not improve the diagnostic accuracy for the detection of epidural CSF. Thus, it lacks a rationale to be included in the routine spontaneous intracranial hypotension work-up. Heavily T2-weighted images with fat saturation provide high accuracy for the detection of an epidural CSF collection. Low accuracy for leak localization is due to an extensive CSF collection spanning several vertebrae (false localizing sign), lack of temporal resolution, and a multiplicity of suspicious lesions, albeit only a single leakage site is present. Thus, dynamic examination is mandatory before targeted treatment is initiated.
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Affiliation(s)
- T Dobrocky
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - A Winklehner
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - P S Breiding
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - L Grunder
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - G Peschi
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
- Department of Interventional, Pediatric, and Diagnostic Radiology (G.P., J.K.)
| | - L Häni
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
| | - P J Mosimann
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - M Branca
- Clinical Trials Unit (M.B.), University of Bern, Bern, Switzerland
| | - J Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
- Department of Interventional, Pediatric, and Diagnostic Radiology (G.P., J.K.)
| | - P Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - A Raabe
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
| | - C T Ulrich
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
| | - J Beck
- Neurosurgery (L.H., A.R., C.T.U., J.B.), University of Bern, Inselspital, Bern, Switzerland
- Department of Neurosurgery (J.B.), Medical Center, University of Freiburg, Freiburg, Germany
| | - J Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
| | - E I Piechowiak
- From the University Institute of Diagnostic and Interventional Neuroradiology (T.D., A.W., P.S.B., L.G., G.P., P.J.M., J.K., P.M., J.G., E.I.P.)
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Utility of heavily T2-weighted MR myelography as the first step in CSF leak detection and the planning of epidural blood patches. J Clin Neurosci 2020; 77:110-115. [PMID: 32402615 DOI: 10.1016/j.jocn.2020.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/01/2020] [Indexed: 11/22/2022]
Abstract
Heavily T2-weighted MR myelography (HT2W-MRM) is emerging as an alternative approach for detection and follow up of CSF leaks. We aimed to assess epidural blood patch (EBP) treatment outcome when using HT2W-MRM as the primary modality for detecting CSF leak and planning EBP placement in routine clinical practice. Since 2018, patients at our institute suspected of having CSF leak, routinely HT2W-MRM instead of CT myelography to determine presence of the leak and identify the EBP target site. Fifty-nine consecutive patients suspected of having a CSF leak underwent HT2W-MRM. After excluding patients with subdural hematoma and poor image quality, 26 (10 men, 16 women; mean age 44.92 ± 12.6 years) patients were included in this study. Patients received EBP on the basis of HT2W-MRM assessments and clinical assessment. Imaging findings and clinical outcome were evaluated. CSF leak was identified in 21 patients (80.8%, 21/26) based HT2W-MRM. Most cases were graded on a confidence scale as CSF leak definitely (n = 13) or probably (n = 3) present. Successful clinical EBP treatment was achieved in 14 of 17 patients (82.4%) after first targeted EBP, and patient symptoms significantly improved after treatment (numerical rating score 6.4 before EBP, 1.3 after EBP, P < 0.001). HT2W-MRM based EBP are the rational and effective choices for CSF leak treatment in routine clinical practice.
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Chazen JL, Robbins MS, Strauss SB, Schweitzer AD, Greenfield JP. MR Myelography for the Detection of CSF-Venous Fistulas. AJNR Am J Neuroradiol 2020; 41:938-940. [PMID: 32354709 DOI: 10.3174/ajnr.a6521] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 02/29/2020] [Indexed: 11/07/2022]
Abstract
CSF-venous fistula is an important treatable cause of spontaneous intracranial hypotension that is often difficult to detect using traditional imaging techniques. Herein, we describe the technical aspects and diagnostic performance of MR myelography when used for identifying CSF-venous fistulas. We report 3 cases in which the CSF-venous fistula was occult on CT myelography but readily detected using MR myelography.
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Affiliation(s)
- J L Chazen
- From the Departments of Radiology (J.L.C., S.B.S., A.D.S.),
| | | | - S B Strauss
- From the Departments of Radiology (J.L.C., S.B.S., A.D.S.)
| | - A D Schweitzer
- From the Departments of Radiology (J.L.C., S.B.S., A.D.S.)
| | - J P Greenfield
- Neurological Surgery (J.P.G.), Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
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29
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Patel DM, Weinberg BD, Hoch MJ. CT Myelography: Clinical Indications and Imaging Findings. Radiographics 2020; 40:470-484. [DOI: 10.1148/rg.2020190135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Dhruv M. Patel
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
| | - Brent D. Weinberg
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
| | - Michael J. Hoch
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
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Spinal Cerebrospinal Fluid Leakage in Spontaneous Intracranial Hypotension: An Intrathecal Gadolinium Enhanced MR-Myelography Study. J Belg Soc Radiol 2020; 104:6. [PMID: 32025622 PMCID: PMC6993594 DOI: 10.5334/jbsr.1877] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objectives: In the present study, the authors presented the intrathecal gadolinium enhanced MR-myelography findings of patients with spontaneous intracranial hypotension. Materials and Methods: Intrathecal gadolinium enhanced MR-myelography (Gd-MR-myelography) examinations between October 2012 and September 2018 in patients having clinical and radiological findings of spontaneous intracranial hypotension were evaluated retrospectively. Sites and types of contrast leakages in 20 patients who met inclusion criteria were reviewed. All patients had undergone T1-fat suppressed sagittal images of cervical, thoracic and lumbar region after the off label intrathecal injection of 1 ml gadolinium-based contrast agent. Results: Patients (18 female, 2 male) are aged between 23 and 62 years-old (mean age: 41.1). Cerebrospinal fluid (CSF) leakages were cervical in 6 patients, thoracic in 5 patients, lumbar in 5 patients. One patient had leakage in multiple levels on both cervical and thoracic region and another patient on both cervical-thoracic and lumbar regions. No patients had adverse effects related to intrathecal injection of gadolinium. Conclusions: Gd-MR-myelography is effective imaging modality to reveal spinal CSF leakages in patients with spontaneous intracranial hypotension.
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Martineau P, Chakraborty S, Faiz K, Shankar J. Imaging of the Spontaneous Low Cerebrospinal Fluid Pressure Headache: A Review. Can Assoc Radiol J 2020; 71:174-185. [PMID: 32063004 DOI: 10.1177/0846537119888395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a significant cause of chronic, postural headaches. Spontaneous intracranial hypotension is generally believed to be associated with cerebrospinal fluid (CSF) leaks, and these leaks can be posttraumatic, iatrogenic, or idiopathic in origin. An integral part of the management of patients with this condition consists of localizing and stopping the leaks. Radiologists play a central role in the workup of this condition detecting leaks using computed tomography, magnetic resonance imaging, or nuclear imaging. In this article, we briefly review SIH and the various imaging modalities, which can be used to identify and localize a spontaneous CSF leak.
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Affiliation(s)
- P Martineau
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - S Chakraborty
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Khunsa Faiz
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
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Kanno H, Yoshizumi T, Nakazato N, Shinonaga M. Predictors of the Response to an Epidural Blood Patch in Patients with Spinal Leakage of Cerebrospinal Fluid. J Clin Neurol 2020; 16:1-8. [PMID: 31942752 PMCID: PMC6974819 DOI: 10.3988/jcn.2020.16.1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/21/2022] Open
Abstract
Background and Purpose An epidural blood patch (EBP) is a highly effective therapy for spinal cerebrospinal fluid (CSF) leakage. However, the factors predicting the response to an EBP have not been fully elucidated. The aim of this study was to elucidate factors predicting the response to an EBP. Methods We retrospectively examined the relationship between the response to an EBP and clinical variables of 118 patients with spinal CSF leakage, such as patient age, sex, etiology, interval from the onset to EBP application, CSF opening pressure (OP), radioisotope (RI) cisternography findings, rate of RI remaining in the CSF space, computed tomography (CT) myelography findings, magnetic resonance imaging (MRI) findings, and subjective symptoms (headache, vertigo/dizziness, visual disturbance, nausea, numbness, nuchal pain, back pain/lumbago, fatigability, photophobia, and memory disturbance). The correlations between these variables and the responses to EBPs were analyzed statistically. Results A positive response to an EBP was significantly (p<0.05) correlated with the following variables: <1.5 years from the onset to EBP application, age <40 years, CSF OP <7 cm H2O, epidural CSF leakage in RI cisternography, epidural CSF collection in MRI, <20% RI remaining after 24 hours, orthostatic headache, nausea, nuchal pain, and photophobia. The other variables did not show significant correlations with the responses to EBPs. Conclusions It might be prudent to take the following variables into account when applying an EBP to treat spinal CSF leakage: the interval from the onset to EBP application, age, CSF OP, epidural CSF leakage in RI, epidural CSF collection in MRI, rate of remaining RI, orthostatic headache, nuchal pain, photophobia, and nausea.
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Affiliation(s)
- Hiroshi Kanno
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan.
| | - Tetsuya Yoshizumi
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan
| | - Naomi Nakazato
- Department of Pharmacology, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan
| | - Masamichi Shinonaga
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan.
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Kim S, Hoch MJ, Patel S, Allen JW, Weinberg BD. Evaluation and treatment of spontaneous intracranial hypotension. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Yang Y, Carr K, Serulle Y, Shivashankar R. MRI myelography for diagnosis and targeted blood patching of multilevel thoracic spine CSF leaks: Report of 2 cases. Radiol Case Rep 2019; 14:981-985. [PMID: 31194096 PMCID: PMC6551536 DOI: 10.1016/j.radcr.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 11/17/2022] Open
Abstract
In patients with occult cerebrospinal fluid (CSF) leaks or CSF leak syndrome, orthostatic headaches are a common presenting symptom. Although computed tomography (CT) myelography has historically been the gold standard for diagnosis with radioisotope cisternography as a diagnostic alternative, magnetic resonance imaging (MRI) myelography using intrathecal gadolinium has reported sensitivity of 80%-87%. Two patients with spontaneous orthostatic headaches lasting for several days were diagnosed with CSF leaks at multiple thoracic segments using MRI myelogram with intrathecal gadolinium (Gadavist, Bayer, Whippany, NJ). This allowed for subsequent targeted treatment with CT fluoroscopy guidance, resulting in therapeutic responses within 1-2 treatment with targeted blood patching. Although intrathecal gadolinium is an off-label use, the superior contrast resolution and lack of radiation exposure makes MRI myelography an excellent imaging modality for diagnosing CSF leak, targeting treatment, and monitoring outcomes compared to CT myelography and radioisotope cisternography.
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Edeklev CS, Halvorsen M, Løvland G, Vatnehol SAS, Gjertsen Ø, Nedregaard B, Sletteberg R, Ringstad G, Eide PK. Intrathecal Use of Gadobutrol for Glymphatic MR Imaging: Prospective Safety Study of 100 Patients. AJNR Am J Neuroradiol 2019; 40:1257-1264. [PMID: 31320462 DOI: 10.3174/ajnr.a6136] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/15/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intrathecal contrast-enhanced glymphatic MR imaging has shown promise in assessing glymphatic function in patients with dementia. The purpose of this study was to determine the safety profile and feasibility of this new MR imaging technique. MATERIALS AND METHODS A prospective safety and feasibility study was performed in 100 consecutive patients (58 women and 42 men, 51 ± 19 years of age) undergoing glymphatic MR imaging from September 2015 to August 2018. Short- and long-term serious and nonserious adverse events were registered clinically and by interview after intrathecal administration of 0.5 mL of gadobutrol (1.0 mmol/mL) along with 3 mL of iodixanol (270 mg I/mL). Adverse events are presented as numbers and percentages. RESULTS One serious adverse event (anaphylaxis) occurred in a patient with known allergy to iodine-containing contrast agents (1%). The main nonserious adverse events during the first 1-3 days after contrast injection included severe headache (28%) and severe nausea (34%), though the frequency depended heavily on the diagnosis. After 4 weeks, adverse events had resolved. CONCLUSIONS Intrathecal administration of gadobutrol in conjunction with iodixanol for glymphatic MR imaging is safe and feasible. We cannot conclude whether short-duration symptoms such as headache and nausea were caused by gadobutrol, iodixanol, the lumbar puncture, or the diagnosis. The safety profile closely resembles that of iodixanol alone.
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Affiliation(s)
- C S Edeklev
- From the Department of Neurosurgery (C.S.E., M.H., P.K.E.)
| | - M Halvorsen
- From the Department of Neurosurgery (C.S.E., M.H., P.K.E.)
| | - G Løvland
- Interventional Centre (G.L., S.A.S.V.)
| | | | - Ø Gjertsen
- Department of Radiology and Nuclear Medicine (Ø.G., B.N. R.S., G.R.), Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - B Nedregaard
- Department of Radiology and Nuclear Medicine (Ø.G., B.N. R.S., G.R.), Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - R Sletteberg
- Department of Radiology and Nuclear Medicine (Ø.G., B.N. R.S., G.R.), Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - G Ringstad
- Department of Radiology and Nuclear Medicine (Ø.G., B.N. R.S., G.R.), Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - P K Eide
- From the Department of Neurosurgery (C.S.E., M.H., P.K.E.) .,Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Oslo, Norway
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Chan SM, Chodakiewitz YG, Maya MM, Schievink WI, Moser FG. Intracranial Hypotension and Cerebrospinal Fluid Leak. Neuroimaging Clin N Am 2019; 29:213-226. [DOI: 10.1016/j.nic.2019.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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37
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Provenzano DA, Pellis Z, DeRiggi L. Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review. Reg Anesth Pain Med 2019; 44:rapm-2019-100422. [PMID: 31023932 DOI: 10.1136/rapm-2019-100422] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 12/13/2022]
Abstract
Gadolinium-based contrast agents (GBCAs) have been suggested as off-label alternatives to iodine-based contrast agents for fluoroscopic imaging during interventional pain procedures. We report a case of accidental intrathecal administration of a GBCA during a neuraxial interventional pain procedure leading to acute gadolinium neurotoxicity, which resulted in encephalopathy and ultimately death. To our knowledge, it is the first published case of fatal intrathecal gadolinium-induced encephalopathy and the first published case of intrathecal gadoteridol causing serious neurologic complications. In addition, the case presented here is placed in context with an associated comprehensive, evidence-based review of the use of gadolinium in interventional pain procedures, addressing gadolinium chemistry and pharmacologic properties, neurotoxicity and radiology. Physicians must be aware that gadolinium poses a significant risk of acute neurotoxicity even in small doses. Until further safety research is performed, GBCAs should not be considered a safe alternative for use in neuraxial interventional spine procedures when there is a risk of inadvertent intrathecal administration.
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Affiliation(s)
| | - Zachary Pellis
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
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Abstract
PURPOSE OF REVIEW Spontaneous intracranial hypotension (SIH) is an underdiagnosed phenomenon predominantly presenting with low cerebrospinal fluid (CSF) pressure and postural headache in setting of CSF leak. The goal of this paper is to provide updates on the pathology, diagnosis, and management of SIH. The utility of multiple imaging modalities and the use of epidural blood patches and fibrin glue polymers are explored. RECENT FINDINGS In regard to diagnosis, new non-invasive modalities in detection of SIH including transorbital ultrasound and serum biomarkers are found. In addition, increased efficacy of large volume and repeated placement of multiple epidural blood patches (EBP) are seen. In addition, the management of refractory SIH using fibrin glue polymers has proved efficacious in recent case series. While the diagnosis may be challenging for clinicians, future research in SIH is leading to more rapid detection methods. Future studies may target optimal use of EBP in comparison to fibrin glue polymers, in addition to new developments in increased understanding of SIH physiology and phenotype.
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Swallow N, Doan LV. Management of Presumed Spontaneous Intracranial Hypotension. A A Pract 2019; 12:93-95. [DOI: 10.1213/xaa.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Degenerative Disorders of the Spine. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_38-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Degenerative Disorders of the Spine. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Amrhein TJ, Kranz PG. Spontaneous Intracranial Hypotension: Imaging in Diagnosis and Treatment. Radiol Clin North Am 2018; 57:439-451. [PMID: 30709479 DOI: 10.1016/j.rcl.2018.10.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article reviews the role of imaging in the diagnosis, management, and treatment of spontaneous intracranial hypotension (SIH). SIH is a debilitating and often misdiagnosed condition caused by either a spinal cerebrospinal fluid (CSF) leak or a CSF to venous fistula. This pathologic condition is identified and localized via spinal imaging, including computed tomographic (CT) myelography, dynamic myelography, dynamic (ultrafast) CT myelography, MR imaging, or MR myelography with intrathecal gadolinium. Treatment of SIH involves conservative measures, surgery, or imaging-guided epidural blood patching.
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Affiliation(s)
- Timothy J Amrhein
- Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA.
| | - Peter G Kranz
- Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA
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Caro-Osorio E, Espino-Ojeda A, Guevara-Maldonado L, Herrera-Castro JC. Utility of magnetic resonance cisternography with intrathecal gadolinium in detection of cerebrospinal fluid fistula associated with Mondini dysplasia in a patient with recurrent meningitis: Case report and literature review. Surg Neurol Int 2018; 9:92. [PMID: 29770252 PMCID: PMC5938894 DOI: 10.4103/sni.sni_449_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/20/2018] [Indexed: 11/04/2022] Open
Abstract
Background The intrathecal contrast-enhanced magnetic resonance cisternography (MRC) is a diagnostic method that has been proven effective in selected patients with various disorders of the cerebrospinal system, including the detection of cerebrospinal fluid (CSF) leaks. The Mondini dysplasia is a malformation of the inner ear characterized by an incomplete cochlear development. The cerebrospinal fistula associated with Mondini dysplasia usually occurs in the first 5-10 years. Case Description The case of a 34-year-old woman with CSF rhinorrhea and recurrent meningitis associated with CSF fistula into the right inner ear, which was detected by MRC with intrathecal gadolinium, is presented. The computed tomography (CT) cisternography failed to detect the exact location of the leak. The right Mondini dysplasia was identified on CT of the temporal bone. A subtotal right-sided petrosectomy and fistula closure into the bony labyrinth were performed. After the procedure the patient no longer presented meningitis or CSF leak. Conclusions The radiological identification of the site of CSF leak through sensitive imaging studies such as MRC with intrathecal gadolinium is crucial for surgical approach.
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Affiliation(s)
- Enrique Caro-Osorio
- Department of Neurosurgery, Tecnologico de Monterrey, Monterrey, Nuevo León, México
| | - Alba Espino-Ojeda
- Department of Neurology, Tecnologico de Monterrey, Monterrey, Nuevo León, México
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Holbrook J, Saindane AM. Imaging of Intracranial Pressure Disorders. Neurosurgery 2017; 80:341-354. [PMID: 27471977 DOI: 10.1227/neu.0000000000001362] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/26/2016] [Indexed: 01/03/2023] Open
Abstract
Intracranial pressure (ICP) is the pressure inside the bony calvarium and can be affected by a variety of processes, such as intracranial masses and edema, obstruction or leakage of cerebrospinal fluid, and obstruction of venous outflow. This review focuses on the imaging of 2 important but less well understood ICP disorders: idiopathic intracranial hypertension and spontaneous intracranial hypotension. Both of these ICP disorders have salient imaging findings that are important to recognize to help prevent their misdiagnosis from other common neurological disorders.
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Affiliation(s)
- John Holbrook
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amit M Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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Ringstad G, Vatnehol SAS, Eide PK. Glymphatic MRI in idiopathic normal pressure hydrocephalus. Brain 2017; 140:2691-2705. [PMID: 28969373 PMCID: PMC5841149 DOI: 10.1093/brain/awx191] [Citation(s) in RCA: 407] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 06/17/2017] [Indexed: 12/17/2022] Open
Abstract
The glymphatic system has in previous studies been shown as fundamental to clearance of waste metabolites from the brain interstitial space, and is proposed to be instrumental in normal ageing and brain pathology such as Alzheimer’s disease and brain trauma. Assessment of glymphatic function using magnetic resonance imaging with intrathecal contrast agent as a cerebrospinal fluid tracer has so far been limited to rodents. We aimed to image cerebrospinal fluid flow characteristics and glymphatic function in humans, and applied the methodology in a prospective study of 15 idiopathic normal pressure hydrocephalus patients (mean age 71.3 ± 8.1 years, three female and 12 male) and eight reference subjects (mean age 41.1 + 13.0 years, six female and two male) with suspected cerebrospinal fluid leakage (seven) and intracranial cyst (one). The imaging protocol included T1-weighted magnetic resonance imaging with equal sequence parameters before and at multiple time points through 24 h after intrathecal injection of the contrast agent gadobutrol at the lumbar level. All study subjects were kept in the supine position between examinations during the first day. Gadobutrol enhancement was measured at all imaging time points from regions of interest placed at predefined locations in brain parenchyma, the subarachnoid and intraventricular space, and inside the sagittal sinus. Parameters demonstrating gadobutrol enhancement and clearance in different locations were compared between idiopathic normal pressure hydrocephalus and reference subjects. A characteristic flow pattern in idiopathic normal hydrocephalus was ventricular reflux of gadobutrol from the subarachnoid space followed by transependymal gadobutrol migration. At the brain surfaces, gadobutrol propagated antegradely along large leptomeningeal arteries in all study subjects, and preceded glymphatic enhancement in adjacent brain tissue, indicating a pivotal role of intracranial pulsations for glymphatic function. In idiopathic normal pressure hydrocephalus, we found delayed enhancement (P < 0.05) and decreased clearance of gadobutrol (P < 0.05) at the Sylvian fissure. Parenchymal (glymphatic) enhancement peaked overnight in both study groups, possibly indicating a crucial role of sleep, and was larger in normal pressure hydrocephalus patients (P < 0.05 at inferior frontal gyrus). We interpret decreased gadobutrol clearance from the subarachnoid space, along with persisting enhancement in brain parenchyma, as signs of reduced glymphatic clearance in idiopathic normal hydrocephalus, and hypothesize that reduced glymphatic function is instrumental for dementia in this disease. The study shows promise for glymphatic magnetic resonance imaging as a method to assess human brain metabolic function and renders a potential for contrast enhanced brain extravascular space imaging.
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Affiliation(s)
- Geir Ringstad
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Per Kristian Eide
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
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Beretta E, Franzini A, Cordella R, Nazzi V, Valentini LG, Franzini A. Surgical "Fat Patch" Improves Secondary Intracranial Hypotension Orthostatic Headache Associated with Lumbosacral Dural Ectasia. World Neurosurg 2017; 107:1053.e7-1053.e10. [PMID: 28866058 DOI: 10.1016/j.wneu.2017.08.145] [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: 05/09/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Secondary intracranial hypotension is a clinical syndrome associated with reduction of cerebrospinal fluid volume and dural continuity violation. The main symptoms are orthostatic headache associated with nausea, vomiting, diplopia, dizziness, and tinnitus. The treatment is usually nonspecific. CASE DESCRIPTION A 37-year-old woman developed secondary intracranial hypotension caused by lumbosacral iatrogenic dural ectasia following detethering surgery. An orthostatic headache was the mainstay of her clinical picture, and it was confirmed by intracranial pressure monitoring. Conservative treatment including spinal blood patch improved symptoms for a limited amount of time (<1 month). Altered compliance of the dural spinal sac was suspected. Therefore thecal sac remodeling by placing autologous fat at the level of the dural ectasia was performed, improving the symptoms for 2 years. CONCLUSION Volumetric reduction of the epidural space may be considered as a valuable therapeutic option in case of intracranial hypotension that is unresponsive to medical treatments and spinal blood patch, as well as when an altered compliance of the dural sac is hypothesized.
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Affiliation(s)
- Elena Beretta
- Department of Neurosurgery Fondazione IRCCS Istituto Neurologico "C. Besta", Milan, Italy.
| | - Andrea Franzini
- Department of Neurosurgery Fondazione IRCCS Istituto Neurologico "C. Besta", Milan, Italy
| | - Roberto Cordella
- Department of Neurosurgery Fondazione IRCCS Istituto Neurologico "C. Besta", Milan, Italy
| | - Vittoria Nazzi
- Department of Neurosurgery Fondazione IRCCS Istituto Neurologico "C. Besta", Milan, Italy
| | - Laura Grazia Valentini
- Department of Neurosurgery Fondazione IRCCS Istituto Neurologico "C. Besta", Milan, Italy
| | - Angelo Franzini
- Department of Neurosurgery Fondazione IRCCS Istituto Neurologico "C. Besta", Milan, Italy
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Maus TP, Schueler BA, Magnuson DJ, Magnuson D. Relative Conspicuity of Gadolinium-Based Contrast Agents in Interventional Pain Procedures. PAIN MEDICINE 2017; 18:651-654. [PMID: 28586445 DOI: 10.1093/pm/pnw312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective To assess the relative radiographic conspicuity of gadolinium-based contrast agents (GBCAs) that may be used in spinal injection procedures when iodine-based contrast agents are contraindicated. Methods Eight GBCAs and three iodinated agents of varying iodine concentrations were radiographed under conditions representative of lumbar spinal injections at four kilovoltage peak (kVp) values. Radiographic contrast of each agent was measured as the percent pixel value difference with respect to background. Results Gadobutrol (Gadovist, 1 mM/mL) had the highest radiographic contrast among the gadolinium agents tested. Measured radiographic contrast correlated with the molar concentration of gadolinium. Gadobutrol radiographic contrast lies between the contrast of iohexol concentrations of 240 and 140 mgI/mL. All agents have decreasing contrast as kVp increases, but GBCAs decrease less than iodine-based agents. Conclusions Gadobutrol is the GBCA with the greatest conspicuity for use in spinal injection procedures. It also has the highest molar concentration of gadolinium, and potential neural toxicity from intrathecal delivery must be considered.
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Affiliation(s)
- Timothy P Maus
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Beth A Schueler
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Dayne Magnuson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Lin JP, Zhang SD, He FF, Liu MJ, Ma XX. The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain 2017; 18:4. [PMID: 28091819 PMCID: PMC5236046 DOI: 10.1186/s10194-016-0708-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/07/2016] [Indexed: 01/03/2023] Open
Abstract
Intracranial hypotension, especially spontaneous intracranial hypotension (SIH), is a well-recognized entity associated with cerebrospinal fluid (CSF) leaks, and has being recognized better in resent years, while still woefully inadequate. An increasing number of factors including iatrogenic factors are realized to involve in development and progression of intracranial hypotension. The diagnosis remains difficult due to the various clinical manifestations, some of which are nonspecific and easily to be neglected. Multiple imaging tests are optional in CSF leakage identification while clinicians are still confronted with difficulties when making selection resulting from superiorities and disadvantages of different imaging tests. Treatments for intracranial hypotension are multifarious but evidence is anecdotal. Values of autologous epidural blood patching (EBP), the mainstay of first-line interventional treatment currently, is getting more and more regards while there are no systematic review of its efficacy and risks. Hereby, the purpose of this review was to reveal the present strategy of intracranial hypotension diagnosis and treatment by reviewing literatures, coupled with our experience in clinical work.
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Affiliation(s)
- Jin-Ping Lin
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Shu-Dong Zhang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Fei-Fang He
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China.
| | - Min-Jun Liu
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Xiao-Xu Ma
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
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Pattichis A(A, Slee M. CSF hypotension: A review of its manifestations, investigation and management. J Clin Neurosci 2016; 34:39-43. [DOI: 10.1016/j.jocn.2016.07.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/28/2016] [Accepted: 07/06/2016] [Indexed: 01/03/2023]
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