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Carroll I, Han L, Zhang N, Cowan RP, Lanzman B, Hashmi S, Barad MJ, Peretz A, Moskatel L, Ogunlaja O, Hah JM, Hindiyeh N, Barch C, Bozkurt S, Hernandez-Boussard T, Callen AL. Long-Term Epidural Patching Outcomes and Predictors of Benefit in Patients With Suspected CSF Leak Nonconforming to ICHD-3 Criteria. Neurology 2024; 102:e209449. [PMID: 38820488 PMCID: PMC11244740 DOI: 10.1212/wnl.0000000000209449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/12/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Spinal CSF leaks lead to spontaneous intracranial hypotension (SIH). While International Classification of Headache Disorders, Third Edition (ICHD-3) criteria necessitate imaging confirmation or low opening pressure (OP) for SIH diagnosis, their sensitivity may be limited. We offered epidural blood patches (EBPs) to patients with symptoms suggestive of SIH, with and without a documented low OP or confirmed leak on imaging. This study evaluates the efficacy of this strategy. METHODS We conducted a prospective cohort study with a nested case-control design including all patients who presented to a tertiary headache clinic with clinical symptoms of SIH who completed study measures both before and after receiving an EBP between August 2016 and November 2018. RESULTS The mean duration of symptoms was 8.7 ± 8.1 years. Of 85 patients assessed, 69 did not meet ICHD-3 criteria for SIH. At an average of 521 days after the initial EBP, this ICHD-3-negative subgroup experienced significant improvements in Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical Health score of +3.3 (95% CI 1.5-5.1), PROMIS Global Mental Health score of +1.8 (95% CI 0.0-3.5), Headache Impact Test (HIT)-6 head pain score of -3.8 (95% CI -5.7 to -1.8), Neck Disability Index of -4.8 (95% CI -9.0 to -0.6) and PROMIS Fatigue of -2.3 (95% CI -4.1 to -0.6). Fifty-four percent of ICHD-3-negative patients achieved clinically meaningful improvements in PROMIS Global Physical Health and 45% in HIT-6 scores. Pain relief following lying flat prior to treatment was strongly associated with sustained clinically meaningful improvement in global physical health at an average of 521 days (odds ratio 1.39, 95% CI 1.1-1.79; p < 0.003). ICHD-3-positive patients showed high rates of response and previously unreported, treatable levels of fatigue and cognitive deficits. DISCUSSION Patients who did not conform to the ICHD-3 criteria for SIH showed moderate rates of sustained, clinically meaningful improvements in global physical health, global mental health, neck pain, fatigue, and head pain after EBP therapy. Pre-treatment improvement in head pain when flat was associated with later, sustained improvement after EBP therapy among patients who did not meet the ICHD-3 criteria. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that epidural blood patch is an effective treatment of suspected CSF leak not conforming to ICHD-3 criteria for SIH.
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Affiliation(s)
- Ian Carroll
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Lichy Han
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Niushen Zhang
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Robert P Cowan
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Bryan Lanzman
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Syed Hashmi
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Meredith J Barad
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Addie Peretz
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Leon Moskatel
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Oyindamola Ogunlaja
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Jennifer M Hah
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Nada Hindiyeh
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Carol Barch
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Selene Bozkurt
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Tina Hernandez-Boussard
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Andrew L Callen
- From the Department of Anesthesiology, Perioperative and Pain Medicine (I.C., L.H., M.J.B., J.M.H.), Stanford Headache Clinic (I.C.), Department of Neurology (N.Z., M.J.B., A.P., L.M., O.O., C.B.), Departments of Neurology and Neurosciences and (by courtesy) Anesthesia (R.P.C.), and Department of Radiology (B.L., S.H.), Stanford University, Palo Alto, CA; Headache Neurology (N.H.), Metrodora Institute, West Valley City, UT; Department of Biomedical Informatics (S.B.), Emory University, Atlanta, GA; Department of Medicine (Biomedical Informatics) (T.H.-B.), Stanford University, Palo Alto, CA; and Department of Radiology (A.L.C.), University of Colorado Anschutz Medical Campus, Aurora
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Madhavan AA, Cutsforth-Gregory JK, Brinjikji W, Benson JC, Johnson-Tesch BA, Liebo GB, Mark IT, Oien MP, Shlapak DP, Yu L, Verdoorn JT. Benefits of Photon-Counting CT Myelography for Localization of Dural Tears in Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2024; 45:668-671. [PMID: 38485199 PMCID: PMC11288524 DOI: 10.3174/ajnr.a8179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 01/08/2024] [Indexed: 05/12/2024]
Abstract
Photon-counting CT is an increasingly used technology with numerous advantages over conventional energy-integrating detector CT. These include superior spatial resolution, high temporal resolution, and inherent spectral imaging capabilities. Recently, photon-counting CT myelography was described as an effective technique for the detection of CSF-venous fistulas, a common cause of spontaneous intracranial hypotension. It is likely that photon-counting CT myelography will also have advantages for the localization of dural tears, a separate type of spontaneous spinal CSF leak that requires different myelographic techniques for accurate localization. To our knowledge, prior studies on photon-counting CT myelography have been limited to techniques for detecting CSF-venous fistulas. In this technical report, we describe our technique and early experience with photon-counting CT myelography for the localization of dural tears.
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Affiliation(s)
- Ajay A Madhavan
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Waleed Brinjikji
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - John C Benson
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Ben A Johnson-Tesch
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Greta B Liebo
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Ian T Mark
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Michael P Oien
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Darya P Shlapak
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Lifeng Yu
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Jared T Verdoorn
- From the Division of Neuroradiology (A.A.M., W.B., J.C.B., B.A.J.-T., G.B.L., I.T.M., M.P.O., D.P.S., L.Y., J.T.V.), Department of Radiology, Mayo Clinic, Rochester, Minnesota
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