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Onuma K, Yanaka K, Nakamura K, Takahashi N, Tajima K, Watanabe D, Ishikawa E. Continuous Epidural Saline Infusion for the Treatment of Spontaneous Intracranial Hypotension. World Neurosurg 2023; 172:e640-e645. [PMID: 36739897 DOI: 10.1016/j.wneu.2023.01.104] [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: 11/17/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Spontaneous intracranial hypotension (SIH) is an increasingly recognized cause of orthostatic headache, but treatment strategies remain controversial. The epidural blood patch is a well-known and widely used treatment in patients with conservative treatment-resistant SIH, but symptoms may not improve even after multiple epidural blood patches, and resistant patients suffer from a lack of appropriate treatment options. Therefore, this study assessed the safety and efficacy of continuous epidural saline infusion (CESI) for SIH treatment. METHODS CESI was performed in 11 consecutive patients affected by conservative treatment-resistant SIH. Patient characteristics were obtained by reviewing medical records retrospectively. Headache intensity was assessed using the numerical rating scale (NRS), and changes in NRS before and after treatment were recorded. RESULTS The average treatment period for CESI was 21.3 ± 9.6 days, and the average follow-up period was 35.0 ± 30.2 months. CESI was without major complications or mortality, and no infections occurred, even without prophylactic antibiotics. The median NRS score before treatment was 10 points, improving to 5 points 1 day after infusion (P < 0.05), 2 points 1 week after infusion (P < 0.05), and 0 points at 3 months after infusion and the final follow-up. No patients have since experienced recurrence of orthostatic headaches. CONCLUSIONS CESI appears to be a safe and well-tolerated procedure for SIH. Further experience may demonstrate this technique to be a viable treatment option for SIH.
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Affiliation(s)
- Kuniyuki Onuma
- Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Kiyoyuki Yanaka
- Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Kazuhiro Nakamura
- Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Nobuyuki Takahashi
- Department of Radiology, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Keiichi Tajima
- Department of Anesthesiology, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Daisuke Watanabe
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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Rajpal S, Nambiar M, Castanelli D, Khabaza A, Asadi H, Jhamb A, Mark Brooks D, Maingard J. Spontaneous Intracranial Hypotension and Spinal Epidural CSF Leaks: Diagnosis and Management. J Clin Neurosci 2023; 111:46-56. [PMID: 36948109 DOI: 10.1016/j.jocn.2023.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/22/2023]
Abstract
Spontaneous intracranial hypotension from spinal cerebrospinal fluid leak is a condition that often presents as orthostatic headaches. Diagnosis and localisation of spinal CSF leaks remain difficult despite multiple imaging modalities that can be used to aid identification. These include traditional CT myelography and MRI as well as newer techniques such as dynamic and digital subtraction myelography. Leaks can be classified into types and optimal localisation and management techniques vary by type of leak. Localisation of a leak can aid in targeting treatment such as an epidural blood patch if conservative measures fail. Where unsuccessful, repeated blood patches and novel techniques can be used to improve patient symptoms. Much of this condition is not well understood and evidence is lacking, with many avenues for potential research.
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Affiliation(s)
- Simran Rajpal
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Victoria, Australia.
| | - Mithun Nambiar
- Monash Imaging, Monash Health, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Damian Castanelli
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Ali Khabaza
- Monash Imaging, Monash Health, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Hamed Asadi
- Department of Neuro-Interventional Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia; School of Medicine, Deakin University, Waurn Ponds, Geelong, Victoria, Australia
| | - Ash Jhamb
- Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Neuro-Interventional Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Julian Maingard
- Department of Neuro-Interventional Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Department of Neuro-Interventional Radiology, St Vincent's Hospital, Fitzroy, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia; School of Medicine, Deakin University, Waurn Ponds, Geelong, Victoria, Australia
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Chen HC, Chai JW, Wu CC, Chen PL, Teng CL. Magnetic resonance imaging predicted the therapeutic response of patients with spinal cerebrospinal fluid leakage undergoing targeted epidural blood patch. Br J Radiol 2022; 95:20210841. [PMID: 34762485 PMCID: PMC8722244 DOI: 10.1259/bjr.20210841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Most patients with spinal cerebrospinal fluid (CSF) leakage require an epidural blood patch (EBP); however, the response to treatment is varied. This study aimed to compare the MRI findings at follow-up between EBP effective and non-effective groups and to identify imaging findings that predict EBP treatment failure. METHODS We retrospectively reviewed 48 patients who received EBP treatment for spinal CSF leakage. These patients were stratified into two groups: EBP effective (n = 27) and EBP non-effective (n = 21) using the results of the 3 month MRI as the end point. RESULTS Compared to the EBP non-effective group, the patients in the EBP effective group had a lower spinal CSF leakage number (2.67 vs 12.48; p = 0.001), lower spinal epidural fluid accumulation levels (3.00 vs 7.48; p = 0.004), brain descend (11.11% vs 38.10%; p = 0.027), pituitary hyperemia (18.52% vs 57.14%; p = 0.007), and decreased likelihood of ≥three numbers of spinal CSF leakage (25.93% vs 90.48%; p = 0.001) in the post-EBP MRI. Clinical non-responsiveness (OR: 57.84; 95% CI: 3.47-972.54; p = 0.005) and ≥three numbers of spinal CSF leakage (OR: 15.13; 95% CI: 1.45-159.06; p = 0.023) were associated with EBP failure. Between these variables, ≥three numbers of spinal CSF leakage identified using the post-EBP MRI demonstrated greater sensitivity in predicting EBP failure compared to clinical non-responsiveness (90.48% vs 61.9%). CONCLUSION The number of spinal CSF leakage identified using the post-EBP MRI with a cut-off value of three is an effective predictor of EBP failure. ADVANCES IN KNOWLEDGE Compared to clinical responsiveness, the post-EBP MRI provided a more objective approach to predict the effectiveness of EBP treatment in patients with spinal CSF leakage.
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Nisson PL, Schreck R, Graham JM, Maya MM, Schievink WI. Spontaneous intracranial hypotension secondary to congenital spinal dural ectasia and genetic mosaicism for tetrasomy 10p: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE213. [PMID: 35855416 PMCID: PMC9265171 DOI: 10.3171/case213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spontaneous intracranial hypotension has historically been a poorly understood pathology that is often unrecognized and undertreated. Even more rarely has it been described in pediatric patients with an otherwise benign past medical history. OBSERVATIONS Herein the authors describe one of the youngest patients ever reported, a 2-year-old girl who developed severe headaches, nausea, and vomiting and experienced headache relief after lying down. Imaging revealed tonsillar herniation 14 mm below the foramen magnum, presumed to be a Chiari malformation, along with extensive dural cysts starting from thoracic level T2 down to the sacrum. She was found to have streaky skin pigmentary variation starting from the trunk down to her feet. Genetic analysis of skin biopsies revealed mosaicism for an isodicentric marker chromosome (10p15.3–10q11.2 tetrasomy) in 27%–50% of cells. After undergoing a suboccipital and cervical decompression at an outside institution, she continued to be symptomatic. She was referred to the authors’ hospital, where she was diagnosed with spontaneous intracranial hypotension. LESSONS After receiving a series of epidural blood patches, the patient experienced almost complete relief of her symptoms. To the authors’ knowledge, this is the first time this chromosomal anomaly has ever been reported in a living child, and this may represent a new genetic association with dural ectasia.
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Affiliation(s)
| | | | | | - Marcel M. Maya
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
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Clinical and radiological prognostic factors in spontaneous intracranial hypotension: a case series. Neurol Sci 2020; 41:475-477. [DOI: 10.1007/s10072-020-04664-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chung DJ, Liounakos J, Abrams K, Siomin V. Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions. Cureus 2020; 12:e8089. [PMID: 32542144 PMCID: PMC7292696 DOI: 10.7759/cureus.8089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Intracranial hypotension (IH) is a relatively common condition associated with low cerebrospinal (CSF) pressure. The most typical symptom is orthostatic headache, although neurological deficits and changes in the level of consciousness, such as encephalopathy, stupor, and coma, may also occur. Uncomplicated CSF hypotension headaches generally resolve with rest, hydration, and analgesia. However, persistent cases may require an epidural blood patch (EBP) for resolution. Our report presents the case of a 50-year-old male with a history of intravenous (IV) drug abuse, positive for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) antibodies, who was admitted for new-onset headache and brain magnetic resonance imaging (MRI) findings suggesting CSF hypotension. The patient subsequently developed altered mental status with agonizing respirations, prompting intubation and admission to the intensive care unit (ICU) with neurosurgery consult. The initial exam revealed fixed and dilated pupils, suggestive of severe IH with brain herniation and the decision was made to proceed with an emergent intrathecal infusion with intraparenchymal intracranial pressure (ICP) monitoring, combined with EBP. A substantial clinical improvement was noted following the procedure. Within 45 minutes, the patient's mental status improved to normal and pupillary dilation and areflexia were no longer observed. While the procedure may need to be repeated in cases of late deterioration, this report provides evidence that intrathecal bolus saline infusion with simultaneous ICP monitoring may be considered an effective measure to treat extreme cases of IH with associated brain herniation. If performed in a timely fashion, improvement of ICP numbers, and clinical resolution can be quite rapid.
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Affiliation(s)
- Douglas J Chung
- Neurological Surgery, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | | | - Kevin Abrams
- Neuroradiology, Baptist Hospital of Miami, Baptist Health South Florida, Miami, USA
| | - Vitaly Siomin
- Neurological Surgery, Miami Cancer Institute, Baptist Health South Florida, Miami, USA
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