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Callen AL, Han L, Pisani Petrucci SL, Andonov N, Lennarson P, Birlea M, O'Brien C, Wilhour D, Anderson A, Bennett JL, Carroll IR. Patterns of clinical and imaging presentations in patients with spontaneous intracranial hypotension due to spinal cerebrospinal fluid venous fistula: A single-center retrospective cross-sectional study. Headache 2024; 64:939-949. [PMID: 39129307 DOI: 10.1111/head.14805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/29/2024] [Accepted: 07/01/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVE To identify distinct clinical or imaging subtypes of spontaneous intracranial hypotension (SIH) due to spinal cerebrospinal fluid (CSF) venous fistula (CVF). BACKGROUND Spontaneous intracranial hypotension is classically understood to present clinically with an orthostatic headache and stereotyped brain magnetic resonance imaging (MRI) findings; however, most prior literature examining clinical and brain MRI features of SIH has focused on all types of spinal CSF leaks concurrently. This study aimed to evaluate whether data support the possibility of internally consistent subtypes based on brain imaging features and clinical symptoms analogous to those seen in primary headache syndromes. METHODS This retrospective cross-sectional single-institution study included 48 consecutive patients meeting the International Classification of Headache Disorders, 3rd edition criteria for SIH due to CVF. Clinical symptoms, pre-treatment brain MRI, and symptom duration were analyzed. Clinical and MRI data were analyzed to identify patterns and associations between symptoms and imaging findings. RESULTS A total of 20 males and 28 females were evaluated, with a mean (standard deviation) age of 61 (10) years. In all, 44/48 (92%) patients experienced headaches, though 18/48 (40%) did not endorse relief when flat, including six of the 48 (13%) with worsening symptoms when flat. In all, 19/48 (40%) patients reported at least one migraine symptom, and six of the 48 (13%) presented with at least one migraine symptom and had no relief when flat. Clinical symptoms clustered primarily into a "classic" presentation consisting of relief when flat, occipital head pain, comorbid neck pain, a pressure/throbbing headache quality, and an "atypical" presentation that was characterized by having several differences: less relief when flat (nine of 22 (41%) vs. 20/23 (87.0%), p = 0.002; odds ratio [OR] 0.110, 95% confidence interval [CI] 0.016-0.53), more frontal head pain (14/22 (64%) vs. one of 23 (4%), p < 0.001; OR 35.0, 95% CI 4.2-1681.0), less neck pain (two of 21 (4.5%) vs. nine of 13 (69.6%), p < 0.001; OR 0.023, 95% CI 0.0005-0.196), and more stabbing/sharp headache quality (nine of 22 (41%) vs. two of 23 (9%), p = 0.017; OR 7.0, 95% CI 1.18-75.9). Brain MRI findings clustered into three groups: those presenting with most imaging findings of SIH concurrently, those with brain sag but less pachymeningeal/venous engorgement, and those with pachymeningeal/venous engorgement but less brain sag. CONCLUSION This study highlights the clinical and imaging diversity among patients with SIH due to CVF, challenging the reliance on classic orthostatic headache alone for diagnosis. The findings suggest the existence of distinct SIH subtypes based on clinical and imaging presentations, underscoring the need for comprehensive evaluation in patients with suspected CVF. Future research should further elucidate the relationship between clinical symptoms and imaging findings, aiming to refine diagnostic criteria and enhance understanding of SIH's pathophysiology.
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Affiliation(s)
- Andrew L Callen
- Department of Radiology, Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lichy Han
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Samantha L Pisani Petrucci
- Department of Radiology, Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nadya Andonov
- Department of Radiology, Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Peter Lennarson
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marius Birlea
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Chantal O'Brien
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Danielle Wilhour
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Abigail Anderson
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeffrey L Bennett
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Programs in Neuroscience and Immunology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ian R Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
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Ellwood SJ, Mootz AA, Carabuena JM, Farber MK, Reale SC. Management of sporadic intracranial vascular malformations in pregnancy: a retrospective analysis. Int J Obstet Anesth 2024; 58:103989. [PMID: 38614896 DOI: 10.1016/j.ijoa.2024.103989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/20/2023] [Accepted: 03/13/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Sporadic intracranial vascular malformations can pose significant risk to parturients, and additional reports of management may inform patient care. Here we describe the peripartum management of parturients with intracranial vascular malformations. METHODS After Institutional Review Board approval, we performed a retrospective analysis of parturients with a known sporadic intracranial vascular malformation including cavernous malformation, developmental venous anomaly, or arteriovenous malformation who delivered at our institution between 2007 and 2020. RESULTS We identified 10 parturients (five cavernous malformations, three developmental venous anomalies, and two arteriovenous malformations) with 16 deliveries. Among all deliveries, 13 (81.3%) were cesarean deliveries without trial of labor; 11 of these (84.6%) received a single-shot spinal and two (15.4%) received an epidural for surgical anesthesia. Two deliveries (12.5%) began with attempted trial of labor but ultimately required cesarean delivery for failure to progress; one of these cases received epidural anesthesia and the other received combined spinal-epidural anesthesia. One delivery was via spontaneous vaginal delivery with epidural analgesia. Overall, our study's cesarean delivery rate was 93.8% and spontaneous vaginal delivery rate was 6.2%. Three of 16 pregnancies were complicated by seizure, obstructive hydrocephalus, or intracranial hemorrhage. There were no intensive care unit admissions or maternal deaths. CONCLUSIONS In our case series of 16 deliveries, there were no complications directly resulting from neuraxial procedures. It remains unclear whether intracranial developmental venous anomalies or unruptured arteriovenous malformations impart increased risk during pregnancy. Antepartum planning with a multidisciplinary team approach enables risk stratification and optimal management.
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Affiliation(s)
- S J Ellwood
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.
| | - A A Mootz
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - J M Carabuena
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - M K Farber
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - S C Reale
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
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Yang H, Wei XS, Gong J, Du XM, Feng HB, Su C, Gilmore C, Yue C, Yu SB, Li C, Sui HJ. The relationship between myodural bridge, atrophy and hyperplasia of the suboccipital musculature, and cerebrospinal fluid dynamics. Sci Rep 2023; 13:18882. [PMID: 37919345 PMCID: PMC10622500 DOI: 10.1038/s41598-023-45820-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023] Open
Abstract
The Myodural Bridge (MDB) is a physiological structure that is highly conserved in mammals and many of other tetrapods. It connects the suboccipital muscles to the cervical spinal dura mater (SDM) and transmits the tensile forces generated by the suboccipital muscles to the SDM. Consequently, the MDB has broader physiological potentials than just fixing the SDM. It has been proposed that MDB significantly contributes to the dynamics of cerebrospinal fluid (CSF) movements. Animal models of suboccipital muscle atrophy and hyperplasia were established utilizing local injection of BTX-A and ACE-031. In contrast, animal models with surgical severance of suboccipital muscles, and without any surgical operation were set as two types of negative control groups. CSF secretion and reabsorption rates were then measured for subsequent analysis. Our findings demonstrated a significant increase in CSF secretion rate in rats with the hyperplasia model, while there was a significant decrease in rats with the atrophy and severance groups. We observed an increase in CSF reabsorption rate in both the atrophy and hyperplasia groups, but no significant change was observed in the severance group. Additionally, our immunohistochemistry results revealed no significant change in the protein level of six selected choroid plexus-CSF-related proteins among all these groups. Therefore, it was indicated that alteration of MDB-transmitted tensile force resulted in changes of CSF secretion and reabsorption rates, suggesting the potential role that MDB may play during CSF circulation. This provides a unique research insight into CSF dynamics.
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Affiliation(s)
- Heng Yang
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Xiao-Song Wei
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Jin Gong
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Xue-Mei Du
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Hong-Bo Feng
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Chang Su
- The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | | | - Chen Yue
- Department of Gynecology ands Obstetrics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - Sheng-Bo Yu
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Chan Li
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China.
| | - Hong-Jin Sui
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China.
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Zhang XH, Gong J, Song Y, Hack GD, Jiang SM, Yu SB, Song X, Zhang J, Yang H, Cheng J, Sui HJ, Zheng N. An anatomical study of the suboccipital cavernous sinus and its relationship with the myodural bridge complex. Clin Anat 2023. [PMID: 37096831 DOI: 10.1002/ca.24048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 03/11/2023] [Accepted: 04/10/2023] [Indexed: 04/26/2023]
Abstract
The suboccipital cavernous sinus (SCS) and the myodural bridge complex (MDBC) are both located in the suboccipital region. The SCS is regarded as a route for venous intracranial outflow and is often encountered during surgery. The MDBC consists of the suboccipital muscles, nuchal ligament, and myodural bridge and could be a power source for cerebrospinal fluid circulation. Intracranial pressure depends on intracranial blood volume and the cerebrospinal fluid. Since the SCS and MDBC have similar anatomical locations and functions, the aim of the present study was to reveal the relationships between them and the detailed anatomical characteristics of the SCS. The study involved gross dissection, histological staining, P45 plastination, and three-dimensional visualization techniques. The SCS consists of many small venous sinuses enclosed within a thin fibrous membrane that is strengthened by a fibrous arch closing the vertebral artery groove. The venous vessels are more abundant in the lateral and medial portions of the SCS than the middle portion. The middle and medial portions of the SCS are covered by the MDBC. Type I collagen fibers arranged in parallel and originating from the MDBC terminate on the SCS either directly or indirectly via the fibrous arch. The morphological features of SCS revealed in this research could serve as an anatomical basis for upper neck surgical procedures. There are parallel arrangements of type I collagen fibers between the MDBC and the SCS. The MDBC could change the blood volume in the SCS by pulling its wall during the head movement.
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Affiliation(s)
- Xu-Hui Zhang
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Jin Gong
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Yang Song
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Gary D Hack
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of dentistry, Baltimore, USA
| | - Si-Meng Jiang
- Postgraduate Training Base, The 967 Hospital of the Joint Logistics Support Force, Jinzhou Medical University, Dalian, China
| | - Sheng-Bo Yu
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Xue Song
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Jing Zhang
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Heng Yang
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Jing Cheng
- Department of Anatomy, Dalian Medical University, Dalian, China
| | - Hong-Jin Sui
- Department of Anatomy, Dalian Medical University, Dalian, China
- Dalian Hoffen Preservation Technique Institution, Dalian, China
| | - Nan Zheng
- Department of Anatomy, Dalian Medical University, Dalian, China
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5
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Huang H, Zhu C, Qin H, Deng L, Huang C, Saifi C, Bondar K, Giordan E, Danisa O, Chung JH, Elgafy H, Fonseka RD, Huang C, Mu Q. Intracranial hemorrhage after spinal surgery: a literature review. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1141. [PMID: 36388815 PMCID: PMC9652572 DOI: 10.21037/atm-22-4929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
Background and Objective Intracranial hemorrhage following spinal surgery is an infrequent but severe complication. Due to its rarity, the etiology, clinical characteristics, and treatment have not yet been fully elucidated. This literature review analyzed the incidence, clinical manifestations, hemorrhage location, current therapeutic strategies, location of operation, and interval time between surgery and bleeding. The objectives of the article were to provide insights for clinicians to promptly identify and prevent potential cases of intracranial hemorrhage. Methods The authors queried PubMed and Web of Science databases using predefined keywords and included published literature reporting on intracranial hemorrhage after spinal surgery. Relevant case reports, case series, and reviews describing the mechanism of intracranial hemorrhage after spinal surgery and meeting diagnostic criteria for intracranial hemorrhage related to spinal surgery were included. Clinico-demographc data, presentations symptoms, location, index surgery type, and neurological outcomes after brain hemorrhage. Oxford Centre Level of Evidence guidelines was used to evaluate the quality of included studies. Descriptive statistics were used to synthesize the results. Key Content and Findings A total of 80 publications of level of evidence IV involving 108 patients with median age at diagnosis was 58.5 years (inter-quartile range: 6-85) were analyzed. The incidence of intracranial hemorrhage was 0.08-0.37% among patients who underwent spinal surgery, and this complication occurred predominantly within 48 hours postoperatively. The initial presentation included headache, reduced level of consciousness, dysarthria, nausea, vomiting, hearing loss, blurred vision, neck rigidity, and delayed recovery from anesthesia. More than half (58.3%) of patients improved, while 23.1% still experienced neurological dysfunctions, and 7.4% died. Conclusions The present study is limited by the levels of evidence of the included studies. There is heterogeneity among cases with respect to patient demographics and medical history. Angiography is critical in assessing the presence and extent of underlying vascular diseases. Intracranial hemorrages may be caused by intraoperative or postoperative cerebrospinal fluid leakage that will lead to intracranial pressure change and induced by intracranial venous or arterial bleeding. The treatment strategies include conservative medical management and surgical treatment. Individualized treatment should be emphasized.
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Affiliation(s)
- Hongxiang Huang
- Department of Neurosurgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Changliang Zhu
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Disease, Yinchuan, Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
| | - Hao Qin
- Clinical Research Center of Digital Medicine and 3D Printing, The People's Hospital of Gaozhou, Maoming, China
| | - Li Deng
- Clinical Research Center of Digital Medicine and 3D Printing, The People's Hospital of Gaozhou, Maoming, China
| | - Chunming Huang
- Clinical Research Center of Digital Medicine and 3D Printing, The People's Hospital of Gaozhou, Maoming, China
| | - Comron Saifi
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Kevin Bondar
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Enrico Giordan
- Neurosurgical Department, Aulss2 Marca Trevigiana, Treviso, Italy
| | - Olumide Danisa
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Jun Ho Chung
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Hossein Elgafy
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Rannulu Dineth Fonseka
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Chuixue Huang
- Department of Neurosurgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Qingchun Mu
- Department of Neurosurgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
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6
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Vallejo MC, Zakowski MI. Post-Dural Puncture Headache Diagnosis and Management. Best Pract Res Clin Anaesthesiol 2022; 36:179-189. [DOI: 10.1016/j.bpa.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
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7
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Predictors Associated with Outcomes of Epidural Blood Patch in Patients with Spontaneous Intracranial Hypotension. J Clin Med 2021; 10:jcm10050922. [PMID: 33670838 PMCID: PMC7957726 DOI: 10.3390/jcm10050922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
An autologous epidural blood patch (EBP) is a mainstay of treatment in patients with spontaneous intracranial hypotension (SIH). EBP, however, is less effective for SIH than post-dural puncture headaches. Therefore, patients with SIH frequently require an additional EBP. The aim of this study was to identify factors associated with poor response to EBP. This single-center retrospective observational study used the institutional registry records of 321 patients who underwent EBP between September 2001 and March 2016. Patients were divided into two groups, a poor responder group, consisting of patients who underwent EBP at least three times or more, and a good responder group of patients who experienced sufficient symptom relief after two or fewer EBP. The demographic characteristics, clinical features, radiologic findings, procedural data, and laboratory data were analyzed. Univariate analysis showed that the neutrophil-to-lymphocyte ratio (NLR; p = 0.004) and platelet-to-lymphocyte ratio (p = 0.015) were significantly lower in poor than in good responders. Multivariate analysis found that NLR was the only independent factor associated with a poor response (odds ratio = 0.720; p = 0.008). These findings indicate that a low NLR was associated with three or more EBP administrations for the sufficient improvement of symptoms in patients with SIH.
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Liu X, Khodeiry MM, Lin D, Sun Y, Lin C, Feng W, Li J, Wang Y, Zhang Q, Cao K, Wang J, Wang N. The Association of Acute Cerebrospinal Fluid Pressure Reduction with Choroidal Thickness. Curr Eye Res 2021; 46:1193-1200. [PMID: 33517795 DOI: 10.1080/02713683.2021.1874024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To investigate the changes in choroidal thickness (CT) after acute cerebrospinal fluid pressure (CSFP) reduction in human subjects. METHODS Before and 15 minutes after diagnostic lumbar puncture (LP), 44 patients underwent measurement of CT by swept-source optical coherence tomography. Thirty-two healthy volunteers imitated the body posture of LP procedure and underwent the same measurement before and 15 minutes after body posture change. RESULTS After CSFP reduction from 10.9 ± 2.1 mmHg at baseline to 8.1 ± 1.5 mmHg (p < 0.001), CT decreased in subfoveal region (p = 0.005), small to medium vessel layer (SMVL, p < 0.001), peripapillary regions in temporal (p = 0.001), nasal (p < 0.001), superior (p < 0.001) and inferior (p < 0.001), respectively. However, no significant change in CT in the control group after body posture change (all p > 0.05). A significant association between CSFP and the ratio of small to medium vessel layer to total choroidal thickness was found (p = 0.009). The CSFP reduction rate was associated with the change rate of SMVL to total CT portion, for each percent decrease in CSFP was associated with a decrease by 0.22% in the rate of SMVL to total CT portion (R2 = 0.125, p = 0.018). CONCLUSIONS A significant decrease in subfoveal CT, small to medium vessel layer and peripapillary region were observed following acute CSFP reduction. The CSFP reduction rate was associated with the change rate of small to medium vessel layer to total CT portion.
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Affiliation(s)
- Xiangxiang Liu
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mohamed M Khodeiry
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.,Research Institute of Ophthalamology, Giza, Egypt
| | - Danting Lin
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yunxiao Sun
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Caixia Lin
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wei Feng
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing, China
| | - Jing Li
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Beijing Eye Institute, Beijing Ophthalmology and Visual Science Key Laboratory, Beijing, China
| | - Yaxing Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Beijing Eye Institute, Beijing Ophthalmology and Visual Science Key Laboratory, Beijing, China
| | - Qing Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Beijing Eye Institute, Beijing Ophthalmology and Visual Science Key Laboratory, Beijing, China
| | - Kai Cao
- Beijing Eye Institute, Beijing Ophthalmology and Visual Science Key Laboratory, Beijing, China
| | - Jiawei Wang
- Department of Neurology and Medical Research Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ningli Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Beijing Eye Institute, Beijing Ophthalmology and Visual Science Key Laboratory, Beijing, China
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