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Kim JK, Lee HY, Kim HY, Kwak MY. A hidden pathophysiology of endolymphatic hydrops: case report of a patient with spontaneous intracranial hypotension presenting with sudden sensorineural hearing loss with vertigo. Front Neurol 2024; 15:1394534. [PMID: 38645745 PMCID: PMC11026624 DOI: 10.3389/fneur.2024.1394534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Spontaneous intracranial hypotension (SIH) is characterized by decreased cerebrospinal fluid (CSF) volume due to leakage through the dural membrane. We present the case of a patient with SIH manifested by fluctuating low-frequency hearing loss, tinnitus, and vertigo. In this patient, endolymphatic hydrops in the cochlea and saccule were visualized by means of a special sequence of inner ear magnetic resonance imaging scans, with a gadolinium-based contrast agent administered intravenously. Endolymphatic hydrops is a potential underlying pathophysiology of SIH-associated hearing impairment. We hypothesize that SIH may be a rare cause of endolymphatic hydrops.
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Affiliation(s)
- Jong Kwan Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
| | - Ho Yun Lee
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ha Youn Kim
- Department of Radiology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
| | - Min Young Kwak
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
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2
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Boczarska-Jedynak M, Stompel D. Headache associated with intracranial hypotension: diagnostic challenges and difficulties in everyday neurological practice. Neurol Neurochir Pol 2024; 58:21-30. [PMID: 38393961 DOI: 10.5603/pjnns.97407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/26/2023] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
Low pressure of cerebrospinal fluid (CSF) is a rare cause of headache, except when the patient undergoes a lumbar puncture. Headache associated with a low CSF pressure i.e. intracranial hypotension causes diagnostic difficulties. Headaches related to spontaneous intracranial hypotension (SIH) pose a significant diagnostic challenge in everyday neurological practice. Patients with headaches due to SIH are usually diagnosed only after a long delay. Diagnostic problems may result in unnecessary invasive diagnostic procedures, or even neurosurgical operations. Diagnosing headaches attributed to SIH requires the consideration of several clinical scenarios, and the disease's features causing primary or secondary disturbances. In this review, we discuss the differential diagnosis of SIH-related headaches with reference to accumulated knowledge, including meta-analyses, guidelines, casuistry, and the applicable criteria of the International Classification of Headache Disorders. In addition, we discuss head and spine magnetic resonance imaging abnormalities, which may indicate intracranial hypotension.
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Affiliation(s)
| | - Daniel Stompel
- Health Institute Dr. Boczarska-Jedynak, Oswiecim, Poland
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3
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Jesse CM, Schär RT, Goldberg J, Fung C, Ulrich CT, Dobrocky T, Piechowiak EI, Schankin CJ, Beck J, Raabe A, Häni L. Patient-reported symptomatology and its course in spontaneous intracranial hypotension - Beware of a chameleon. Clin Neurol Neurosurg 2024; 236:108087. [PMID: 38134757 DOI: 10.1016/j.clineuro.2023.108087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Although orthostatic headache is the hallmark symptom of spontaneous intracranial hypotension (SIH), patients can present with a wide range of different complaints and thereby pose a diagnostic challenge for clinicians. Our aim was to describe and group the different symptoms associated with SIH and their course over time. METHODS We retrospectively surveyed consecutive patients diagnosed and treated for SIH at our institution from January 2013 to May 2020 with a specifically designed questionnaire to find out about their symptomatology and its course. RESULTS Of 112 eligible patients, 79 (70.5%) returned the questionnaire and were included in the analysis. Of those, 67 (84.8%) reported initial orthostatic headaches, whereas 12 (15.2%) denied having this initial symptom. All except one (98.7%) patients reported additional symptoms: most frequently cephalic pressure (69.6%), neck pain (68.4%), auditory disturbances (59.5%), nausea (57%), visual disturbances (40.5%), gait disturbance (20.3%), confusion (10.1%) or sensorimotor deficits (21.5%). Fifty-seven (72.2%) patients reported a development of the initial symptoms predominantly in the first three months after symptom onset. Age and sex were not associated with the symptomatology or its course (p > 0.1). CONCLUSION Although characteristic of SIH, a relevant amount of patients present without orthostatic headaches. In addition, SIH can manifest with non-orthostatic headaches at disease onset or during the course of the disease. Most patients report a wide range of associated complaints. A high degree of suspicion is crucial for an early diagnosis and targeted treatment.
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Affiliation(s)
- Christopher Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany; Department of Neurosurgery, Lindenhofspital, Bern, Switzerland
| | | | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eike Immo Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Cahal M, Roth J, Ungar OJ, Brinjikji W. Fluctuating hearing loss secondary to spontaneous intracranial hypotension: A case report and review of the literature. Interv Neuroradiol 2023:15910199231221863. [PMID: 38146166 DOI: 10.1177/15910199231221863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE Fluctuating sensorineural hearing loss (SNHL) has multiple etiologies, most commonly Ménière's disease (MD), recurrent sudden SNHL, and autoimmune inner ear disorders. Fluctuating SNHL has rarely been described as a symptom of spontaneous intracranial hypotension (SIH). PATIENT A 39-year-old previously healthy female presented with "Ménière's like" symptoms responsive to steroid treatment, which worsened during the day and improved in the supine position. Conservative treatment for MD consisting of low salt and caffeine diet and betahistine medication yielded no improvement. Secondary revision of brain imaging scans showed signs indicative of SIH, and a spinal cerebrospinal fluid leak was ultimately found and treated by a novel technique of transvenous fistula embolization by means of Onyx® glue, leading to gradual clinical improvement and near-complete resolution of symptoms. CONCLUSION SIH should be considered as part of the differential diagnosis of fluctuating SNHL. Clinical and radiological features should be known and sought. We suspect that early diagnosis and treatment can lead to cure and prevent permanent auditory damage.
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Affiliation(s)
- Michal Cahal
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ellens NR, Schartz D, Ismail R, Kessler A, Ellika S, Akkipeddi SMK, Rahmani R, Bender MT. Efficacy of transvenous embolization of CSF-venous fistula in spontaneous intracranial hypotension: Case-series. Interv Neuroradiol 2023:15910199231221449. [PMID: 38130106 DOI: 10.1177/15910199231221449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension is a debilitating neurological condition which can be caused by a cerebrospinal fluid-venous fistula. Transvenous embolization is a promising technique to provide minimally invasive yet durable treatment. METHODS A retrospective single-center case series was performed on all patients who underwent transvenous embolization of a cerebrospinal fluid (CSF)-venous fistula. Clinical and radiographic parameters, including Bern score, were reported preoperatively and at 3-month follow-up. RESULTS Six patients underwent embolization of a CSF-venous fistula. All fistulae were located in the thoracic spine and technical success was achieved in all cases. Three patients had symptom resolution, two had significant improvement, and one had stable symptoms on follow-up. The mean Bern score was 6.83 (SD = 1.47) preoperatively and 1.83 (SD = 1.64) postoperatively with a mean improvement in Bern score of 5.0 (SD = 1.9, p = 0.0013). CONCLUSIONS CSF-venous fistulas are an increasingly recognized clinical entity which may be treated with transvenous embolization. This case series serves to further validate this technique and suggests it can be performed with similar outcomes in lower volume centers.
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Affiliation(s)
- Nathaniel R Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Shehenaz Ellika
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
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6
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Li S, Yang Y, Zuo J, Du N, Kou G. Reversible cerebral vasoconstriction syndrome following intracranial hypotension in a postpartum patient: a case report and literature review. Front Neurol 2023; 14:1281074. [PMID: 37900590 PMCID: PMC10602719 DOI: 10.3389/fneur.2023.1281074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Reversible cerebral vasoconstriction syndrome (RCVS) is a potentially life-threatening neurological disorder, rarely linked to intracranial hypotension. The presentation showed a patient with intracranial hypotension after peridural anesthesia who experienced RCVS during the early postpartum period, suggesting a potential involvement of intracranial hypotension in RCVS occurrence. Case report A young female of 29 years of age initially developed an orthostatic headache after undergoing a painless delivery with lumbar epidural anesthesia. Intracranial hypotension was considered the underlying cause. Her headache was partially resolved after intravenous fluid therapy and strict bed rest. After 2 days, the patient had a new onset thunderclap headache with generalized seizures, cortical blindness, and elevated blood pressure. An MRI scan revealed high signal intensity within the temporal, parietal, and occipital lobes, left caudate nucleus, and right cerebellum on T2-FLAIR imaging with vasogenic edema. MR angiography indicated multifocal, segmental, diffuse narrowing affecting the cerebral arteries that are large and medium. An RCVS2 score was six, and the patient was diagnosed with RCVS. She was managed conservatively, quickly improving her symptoms. After 10 days, a follow-up MRI indicated a significant reduction in the abnormal signal, and a substantial resolution of the constriction of the cerebral artery constriction was confirmed by MR angiography. Conclusion Intracranial hypotension could potentially lead to RCVS in postpartum patients, and it may be triggered by cerebral vasospasm secondary to intracranial hypotension.
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Affiliation(s)
- Shuhua Li
- Department of Infectious Diseases, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
| | - Yi Yang
- Department of Neurology, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiacai Zuo
- Department of Neurology, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
| | - Ningli Du
- Department of Infectious Diseases, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
| | - Guoxian Kou
- Department of Infectious Diseases, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
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Chau D, Barnard ZR, Muelleman TJ, Olszewski AM, D'Agostino AK, Maya MM, Nisson PL, Peng KA, Schievink WI, Lekovic GP. Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23300. [PMID: 37728168 PMCID: PMC10595135 DOI: 10.3171/case23300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory. OBSERVATIONS A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula. LESSONS Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.
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Affiliation(s)
- Dominic Chau
- 1Division of Neurosurgery, House Institute, Los Angeles, California
| | | | | | - Adam M Olszewski
- 1Division of Neurosurgery, House Institute, Los Angeles, California
| | | | - Marcel M Maya
- 4Imaging, Cedars-Sinai Hospital and Medical Center, Los Angeles, California
| | | | - Kevin A Peng
- 2Division of Neuro-otology, House Institute, Los Angeles, California
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Boddu SP, Goodman BP, VanderPluym JH. Headache rounds: Postural headache in a patient with squamous cell carcinoma. Headache 2023; 63:1186-1192. [PMID: 37635384 DOI: 10.1111/head.14615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/20/2023] [Accepted: 07/28/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Sayi P Boddu
- Mayo Clinic Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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9
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Gaini LM, Battilocchi L, Conte G, Gaffuri M, Zanetti D, Pignataro L, Torretta S. Bilateral Sensorineural Hearing Loss Related to a Skull Base Spontaneous Cerebrospinal Fluid Leak: A Case Report and Literature Review. Ear Nose Throat J 2023:1455613231191372. [PMID: 37551677 DOI: 10.1177/01455613231191372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a rare condition characterized by orthostatic headache, pulsatile tinnitus, vertigo, nausea, and fluctuating hearing loss; this latter seems to be due to the development of cochlear endolymphatic hydrops following negative cerebrospinal fluid (CSF) pressure transmitted to the perilymphatic space through a patent cochlear aqueduct. We here describe a case of bilateral progressive sensorineural hearing loss (SNHL) due to intracranial hypotension caused by an undiagnosed spontaneous CSF leak from a skull base defect in a middle-aged woman. To the best of our knowledge, this is the first report describing a SNHL in a patient affected by SIH secondary to sphenoidal CSF leak.
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Affiliation(s)
- Lorenzo Maria Gaini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Otolaryngology and Head and Neck Surgery, Milan, Italy
| | - Ludovica Battilocchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Otolaryngology and Head and Neck Surgery, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giorgio Conte
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neuroradiology Unit, Milan, Italy
- University of Milan, Department of Medical-Surgical Physiopathology and Transplantation, Milan, Italy
| | - Michele Gaffuri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Otolaryngology and Head and Neck Surgery, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Diego Zanetti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Audiology Unit, Milan, Italy
| | - Lorenzo Pignataro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Otolaryngology and Head and Neck Surgery, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Sara Torretta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Otolaryngology and Head and Neck Surgery, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Siau Tiak H, Zahari M. Isolated Abducens Nerve Palsy Following Spinal Anesthesia. Cureus 2023; 15:e41298. [PMID: 37539413 PMCID: PMC10394576 DOI: 10.7759/cureus.41298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/05/2023] Open
Abstract
A healthy 28-year-old lady, para 1, presented to the emergency department with persistent frontal headache, nausea, and vomiting following an emergency cesarean section four days ago. She experienced difficulties with six failed attempts of spinal anesthesia intrapartum before conversion to general anesthesia. A 25-gauge Whitacre needle was utilized for administering spinal anesthesia under a sitting position. The anesthetist noticed a loss of resistance upon needle insertion, but only a negligible amount of cerebrospinal fluid was obtained upon removing the stylet. The patient underwent an emergency cesarean section due to fetal distress, and she was not in labor during the attempts of spinal anesthesia. Otherwise, the cesarean section lasted for an hour and was uneventful. No intrapartum eclampsia or pre-eclampsia. She was diagnosed with post-dural puncture headache, and her symptoms improved after receiving intravenous hydration, oral caffeine, and non-steroidal anti-inflammatory drug (NSAIDs). However, on the sixth day after the spinal anesthesia, she suddenly developed double vision. Examination showed bilateral visual acuity was measured at 6/7.5. No proptosis or ptosis was noted. The relative afferent pupillary defect was negative with no anisocoria. Both eyes were orthophoria with normal head posture. Extraocular muscles revealed a right abduction restriction of -1 with the patient complaining of binocular horizontal diplopia at the right gaze, consistent with right abducens nerve palsy. Systemic neurological findings were normal, and imaging results were unremarkable. Diagnosis of right abducens nerve palsy post-dural puncture was made clinically. The patient was keen on conservative management instead of blood patch therapy. Hence, she was treated supportively via uni-ocular patching to relieve diplopia. Spontaneous complete recovery of the right abducens nerve palsy was observed after three weeks. Cranial nerve palsy is a rare complication reported following spinal anesthesia, with the abducens nerve being the commonest nerve involved. Although it is not always benign, the presented case showed spontaneous complete recovery of the right abducens nerve palsy after three weeks. Awareness of this uncommon complication will avoid unnecessary distress and investigative burden to both the patient and the doctor.
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Affiliation(s)
- Hing Siau Tiak
- Ophthalmology, University Malaya Eye Research Centre, Kuala Lumpur, MYS
| | - Mimiwati Zahari
- Ophthalmology, University Malaya Eye Research Centre, Kuala Lumpur, MYS
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11
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Roriz C, Canelas MA, Pereira E. Intracranial Hypotension Syndrome: The Importance of Neurointensive Care. Cureus 2023; 15:e42673. [PMID: 37649930 PMCID: PMC10463094 DOI: 10.7759/cureus.42673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 09/01/2023] Open
Abstract
Surgical procedures involving the spine can result in various complications, including vascular, nerve root and dura mater injury, surgical wound infection, and hematoma formation. Unintentional durotomy is a frequent complication of these procedures (up to 17%). Two clinical cases are reported in which the occurrence of epileptiform activity in the form of generalized tonic-clonic seizures after instrumentation of the dorsal and lumbar spine raised suspicion of cerebrospinal fluid (CSF) fistula. In both cases, the diagnostic suspicion and early approach allowed for the adoption of a timely medical and surgical plan, with the aim of reducing the volume of lost CSF as well as the potential neurological dysfunction resulting from this surgical complication.
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Affiliation(s)
- Carolina Roriz
- Intensive Care Unit, Centro Hospitalar de Leiria, Leiria, PRT
| | - Maria Ana Canelas
- Intensive Care Unit, Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, PRT
| | - Eduarda Pereira
- Neurocritical Care Unit and Intensive Care, Hospital São João, Porto, PRT
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12
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Han S, Toyama S. Engorged cervical epidural venous plexus presenting as posterior cervical pain after accidental dural puncture. Anaesth Rep 2023; 11:e12250. [PMID: 37869173 PMCID: PMC10589824 DOI: 10.1002/anr3.12250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- S. Han
- Department of AnesthesiologyTokyo Medical and Dental University HospitalTokyoJapan
| | - S. Toyama
- Department of AnesthesiologyTokyo Medical and Dental University, Graduate School of Medical and Dental SciencesTokyoJapan
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Mariappan R, Kumar S, Raju K, Daniel D, Nair SC, Subramani S. Comparing two techniques of performing an epidural catheter-assisted epidural blood patch using a 20 ml syringe versus a 5 ml syringe and its effect on clotting time, the strength of clot retraction and haemolysis - A prospective in vitro study (EC-EBP study). Indian J Anaesth 2023; 67:544-547. [PMID: 37476432 PMCID: PMC10355359 DOI: 10.4103/ija.ija_849_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/15/2023] [Accepted: 04/08/2023] [Indexed: 07/22/2023] Open
Abstract
Background and Aims Epidural blood patch (EBP) is performed by injecting autologous blood into the epidural space using a Tuohy needle. Certain clinical scenarios mandate an epidural catheter (EC)-assisted EBP. Collecting blood in a 20-ml versus 5-ml syringe appears to influence the quality of the clot. This in vitro study compared the techniques of performing the EC-assisted EBP using 20-ml versus 5-ml syringe on clotting time (CT), clot retraction (CR) and haemolysis. Methods This in vitro study was performed in a haematology laboratory. Five consented adult healthy male volunteers donated blood. In the 5-ml syringe technique, blood was injected through an EC, and as it flowed out of the tip, it was collected at the beginning and the end of 1 min. With the 20-ml technique, blood was collected at the beginning and end of the first, second and third minute. The samples were tested for CT, CR and haemolysis by measuring the plasma-free haemoglobin (PFHb). Results Five injections were made using a 5-ml syringe, and another five with a 20-ml syringe. Injection time was shorter in the 5-ml technique (80.80 ± 5.89 vs. 272 ± 28.4 s, P < 0.0001). With the 20-ml technique, CT progressively increased (>15 min), whereas, with the 5-ml syringe, the CT was normal. Both techniques caused mild, insignificant haemolysis (PFHb >0.005 g/dl), without affecting the quality of CR. Conclusion EC-assisted EBP using a 5-ml syringe technique shortens the injection time and deposits fresh blood quickly without affecting CT and CR.
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Affiliation(s)
- Ramamani Mariappan
- Department of Neuroanaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | - Snehil Kumar
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Krishnaprabhu Raju
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dolly Daniel
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sukesh Chandran Nair
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sathya Subramani
- Department of Physiology, Christian Medical College, Vellore, Tamil Nadu, India
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14
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Kamal MA, Henshall DE, Hughes MA. Postoperative Diabetes Insipidus Mimicking Radiological Findings and Symptoms of Intracranial Hypotension: A Case Report. Cureus 2023; 15:e40398. [PMID: 37456409 PMCID: PMC10346128 DOI: 10.7759/cureus.40398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Endocrine disturbances such as diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) are recognized complications of craniopharyngioma surgery, which occur due to damage to structures that produce or store antidiuretic hormone (ADH). Intracranial hypotension is a clinical syndrome that presents with headache and typical radiological features and can occur due to a leak of cerebral spinal fluid (CSF) in operations that involve the opening of the arachnoid (e.g., craniopharyngioma surgery). We describe a patient presenting with headache, radiological evidence of intracranial hypotension, and chronic DI after craniopharyngioma surgery. This occurred in the absence of evidence of a CSF leak. The headache and radiological findings resolved after the identification and treatment of DI. Intracranial hypotension may have occurred secondary to dehydration in chronic DI. A 48-year-old woman presented with progressive visual field loss due to cystic recurrence of a craniopharyngioma. She underwent redo (second) extended endoscopic transsphenoidal surgery, having previously undergone an uncomplicated debulking procedure two years prior. Her redo operation was uneventful, and her vision improved postoperatively. A lumbar drain was placed preoperatively to protect the skull base repair and was removed after 48 hours. In the initial postoperative period, she developed a clinical (polyuria) and biochemical picture consistent with DI, subsequently reverting to a SIADH, after which fluid and sodium homeostasis appeared to normalize, and she was discharged. Two months after discharge, she re-presented with new headaches eased by lying flat. Magnetic resonance imaging (MRI) brain showed bilateral convexity subdural effusions and diffuse pachymeningeal enhancement, suggesting intracranial hypotension and raising concern for postoperative CSF leak. MRI spine did not show a CSF fistula at the site of the previous lumbar drain. Transsphenoidal examination under anesthesia showed a well-healed skull base repair and no evidence of CSF leak. She concurrently reported polyuria and polydipsia. A formal water deprivation test confirmed central DI. Treatment with desmopressin improved her headache, and a follow-up MRI brain showed resolution of the previous stigmata of intracranial hypotension. This case report reminds physicians and neurosurgeons that systemic disorders (such as dehydration) can cause intracranial hypotension.
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Affiliation(s)
- Muhammad A Kamal
- Department of Neurosurgery, Royal Infirmary of Edinburgh, Edinburgh, GBR
| | - David E Henshall
- Deanery of Clinical Sciences, College of Medicine & Veterinary Medicine, The University of Edinburgh, Edinburgh, GBR
- Department of Neurosurgery, Royal Infirmary of Edinburgh, Edinburgh, GBR
| | - Mark A Hughes
- Department of Neurosurgery, Royal Infirmary of Edinburgh, Edinburgh, GBR
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15
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Sultan N, Miran MS, Wooldridge D, Zia M. Post Dural Puncture Subdural Hematoma: A Rare Iatrogenic Complication of Neuraxial Anesthesia. Cureus 2023; 15:e40520. [PMID: 37461760 PMCID: PMC10350308 DOI: 10.7759/cureus.40520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Although post-dural puncture headache is a well-known complication of neuraxial anesthesia, subdural hematoma following epidural injection is a rare but potentially under-recognized complication. The following is the case of a young female patient with no significant past medical history who developed a persistent and severe headache following the introduction of epidural anesthesia for labor induction. Imaging demonstrated multiple small subdural hematomas with findings concerning intracranial hypotension. She eventually underwent a blood patch and reported immediate relief from her headache.
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Affiliation(s)
- Nadia Sultan
- Internal Medicine, University of Missouri Kansas City, Kansas City, USA
| | | | - David Wooldridge
- Internal Medicine, University of Missouri Kansas City, Kansas City, USA
| | - Mudassar Zia
- Internal Medicine, University of Missouri Kansas City, Kansas City, USA
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16
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Utukuri PS, Shih RY, Ajam AA, Callahan KE, Chen D, Dunkle JW, Hunt CH, Ivanidze J, Ledbetter LN, Lee RK, Malu O, Pannell JS, Pollock JM, Potrebic SX, Setzen M, Shih RD, Soares BP, Staudt MD, Wang LL, Burns J. ACR Appropriateness Criteria® Headache: 2022 Update. J Am Coll Radiol 2023; 20:S70-S93. [PMID: 37236753 DOI: 10.1016/j.jacr.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Headache is an ancient problem plaguing a large proportion of the population. At present, headache disorders rank third among the global causes of disability, accounting for over $78 billion per year in direct and indirect costs in the United States. Given the prevalence of headache and the wide range of possible etiologies, the goal of this document is to help clarify the most appropriate initial imaging guidelines for headache for eight clinical scenarios/variants, which range from acute onset, life-threatening etiologies to chronic benign scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Robert Y Shih
- Panel Chair, Uniformed Services University, Bethesda, Maryland
| | | | - Kathryn E Callahan
- Wake Forest School of Medicine, Winston Salem, North Carolina; American Geriatrics Society
| | - Doris Chen
- Stanford University, Stanford, California, Primary care physician
| | - Jeffrey W Dunkle
- Indiana University School of Medicine, Indianapolis, Indiana; Committee on Emergency Radiology-GSER
| | - Christopher H Hunt
- Mayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Omojo Malu
- Fort Belvoir Community Hospital, Fort Belvoir, Virginia; American Academy of Family Physicians
| | | | | | - Sonja X Potrebic
- Southern California Permanente Medical Group, Pasadena, California; American Academy of Neurology
| | - Michael Setzen
- Weill Cornell Medical College, New York, New York; American Academy of Otolaryngology-Head and Neck Surgery
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | - Michael D Staudt
- Oakland University William Beaumont School of Medicine, Rochester, Michigan; American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | - Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Judah Burns
- Specialty Chair, Montefiore Medical Center, Bronx, New York
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17
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Hurtado Andrade MD, Tama E, Atkinson JLD, Chang AY. A False Pituitary Tumor. JCEM Case Rep 2023; 1:luad054. [PMID: 37908583 PMCID: PMC10580463 DOI: 10.1210/jcemcr/luad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Indexed: 11/02/2023]
Abstract
A false pituitary tumor describes pituitary enlargement due to intracranial hypotension. Reported previously primarily in the neurological literature, we present this case referred to endocrinology for evaluation of a pituitary mass. A 24-year-old male was referred to endocrinology for evaluation of pituitary enlargement without a hypo-enhancing lesion on magnetic resonance imaging (MRI). The main symptom reported was headache that was worse in the standing position and in the afternoon. He had no symptoms or signs of pituitary mass-effect, or hormone excess or deficiencies. Past medical history was relevant for a history of nerve schwannoma status post resection with subsequent spinal fusion. Biochemical evaluation of pituitary hormones was normal. Upon review of his pituitary MRI, other abnormalities seen were suggestive of intracranial hypotension. Based on his history and imaging findings, he was diagnosed with intracranial hypotension causing a "false pituitary tumor" rather than pituitary enlargement or abnormality. Further evaluation revealed multiple spinal leaks that were patched. His symptoms subsided within a few days of repair. Endocrinologists should be aware of the possible misdiagnosis of a pituitary mass due to intracranial hypotension.
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Affiliation(s)
- Maria D Hurtado Andrade
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Elif Tama
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | | | - Alice Y Chang
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
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18
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Pradeep A, Madhavan AA, Brinjikji W, Cutsforth-Gregory JK. Incidence of spontaneous intracranial hypotension in Olmsted County, Minnesota: 2019-2021. Interv Neuroradiol 2023:15910199231165429. [PMID: 36945844 DOI: 10.1177/15910199231165429] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND As the myriad clinical and radiographic presentations of spontaneous intracranial hypotension are increasingly recognized, disease prevalence appears to rise. True incidence data remain insufficient. We sought to calculate the incidence of spontaneous intracranial hypotension among the residents of Olmsted County, Minnesota. METHODS Our institution is a quaternary care center for spontaneous intracranial hypotension evaluation and provides primary neurologic care for local residents. All patients who were evaluated at our institution from 2019 to 2021 for spontaneous intracranial hypotension were reviewed, and cases of spontaneous intracranial hypotension with advanced imaging work-up using digital subtraction myelography or dynamic computed tomography myelography were identified. Patients who were residents of Olmsted County were identified. RESULTS Fourteen patients with spontaneous intracranial hypotension were identified in Olmsted County during the study period, all of whom were adults and underwent our institution's standard spontaneous intracranial hypotension work-up. In Olmsted County, the incidence of spontaneous intracranial hypotension was 3.8 per 100,000 adult population, including 3.2 per 100,000 adult females and 2.5 per 100,000 adult males. Seven of 14 patients (50%) had a cerebrospinal fluid-venous fistula. CONCLUSION This study uniquely presents the incidence rate of spontaneous intracranial hypotension in the general population of Olmsted County, Minnesota. Spontaneous intracranial hypotension is more common in women than men and has an overall incidence roughly equivalent to that of aneurysmal subarachnoid hemorrhage in Olmsted County, a widely known neurologic condition. Approximately half the cases of spontaneous intracranial hypotension are due to cerebrospinal fluid-venous fistulas, which generally require specialty expertise for diagnosis and treatment.
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Affiliation(s)
- Aishwarya Pradeep
- Mayo Clinic Alix School of Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
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19
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Minot-This MS, Grinda T, Epaillard N, Guyon D, Jawiche RE, Garcia G, Pistilli B. Intracranial hypotension in a breast cancer patient treated with epidural blood patches. CNS Oncol 2023; 12:CNS94. [PMID: 36876848 PMCID: PMC9996407 DOI: 10.2217/cns-2022-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
We report the case of a patient with metastatic breast cancer who presented with an orthostatic headache. After a comprehensive diagnostic workup including MRI and lumbar puncture, we maintained the diagnosis of intracranial hypotension (IH). The patient was therefore treated with two consecutive non targeted epidural blood patches, resulting in the remission of IH symptoms for 6 months. IH in cancer patients is a rarer cause of headache than carcinomatous meningitis. As the diagnosis can be made by standard examination and the treatment is relatively simple and effective, IH deserves to be better known by oncologists.
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Affiliation(s)
| | - Thomas Grinda
- Department of Medical Oncology, Gustave Roussy, Villejuif, 94800, France
| | - Nicolas Epaillard
- Department of Medical Oncology, Gustave Roussy, Villejuif, 94800, France
| | - David Guyon
- Department of Medical Oncology, Gustave Roussy, Villejuif, 94800, France
| | - Rita El Jawiche
- Department of Anaesthesia, Gustave Roussy, Villejuif, 94800, France
| | - Gabriel Garcia
- Department of Radiology, Gustave Roussy, Villejuif, 94800, France
| | - Barbara Pistilli
- Department of Medical Oncology, Gustave Roussy, Villejuif, 94800, France
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20
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Nimma S, Maurer A, Kampouri D, Wardhan R. Does an Epidural Blood Patch (EBP) for Postdural Puncture Headache (PDPH) From a Lumbar Spinal Drain Necessitate a Distinct Approach? Cureus 2023; 15:e35098. [PMID: 36945261 PMCID: PMC10024888 DOI: 10.7759/cureus.35098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/19/2023] Open
Abstract
An intentional or unintentional dural puncture puts patients at significant risk for a postdural puncture headache (PDPH). When conservative treatments fail, an epidural blood patch (EBP) is offered cautiously due to rare but devastating complications. The literature is abundant with reviews on the management of PDPH in obstetric patients, but there is a paucity of data on the management of PDPH and complications of EBP in patients post spinal drain placement. In this case report, we address the specific concerns that vascular patients may have about the outcomes of large needle sizes and suggest alternative approaches for non-obstetric patients.
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Affiliation(s)
| | - Adrian Maurer
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Dimitrios Kampouri
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Richa Wardhan
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
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21
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Beck J, Hubbe U, Klingler JH, Roelz R, Kraus LM, Volz F, Lützen N, Urbach H, Kieselbach K, Fung C. Minimally invasive surgery for spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension. J Neurosurg Spine 2023; 38:147-152. [PMID: 36087332 DOI: 10.3171/2022.7.spine2252] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/18/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Spinal CSF leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is the treatment of choice for persisting leaks. Surgical approaches vary, and there are no studies in which minimally invasive techniques were used. In this study, the authors aimed to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using nonexpandable tubular retractors. METHODS Consecutive patients with SIH and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study. Surgery was performed via a dorsal 2.5-cm skin incision using nonexpandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications. RESULTS Fifty-eight patients, 65.5% of whom were female (median age 46 years [IQR 36-55 years]), with 38 ventral leaks, 17 lateral leaks, and 2 CSF venous fistulas were included. In 56 (96.6%) patients, the leak could be closed, and in 2 (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak. The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension. CONCLUSIONS Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach is safe and effective for the treatment of spinal CSF leaks. The authors suggest performing a minimally invasive closure of spinal CSF leaks in specialized centers.
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Affiliation(s)
| | | | | | | | | | | | - Niklas Lützen
- 2Neuroradiology, Medical Center, University of Freiburg, Freiburg; and
| | - Horst Urbach
- 2Neuroradiology, Medical Center, University of Freiburg, Freiburg; and
| | - Kristin Kieselbach
- 3Interdisciplinary Pain Center, Medical Center, University of Freiburg, Freiburg, Germany
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22
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Antonescu-Ghelmez D, Butnariu I, Antonescu F, Maier C, Moraru A, Bucur AI, Anghel DN, Tuţă S. Thunderclap headache revealing dural tears with symptomatic intracranial hypotension: Report of two cases. Front Neurol 2023; 14:1132793. [PMID: 36908611 PMCID: PMC9996024 DOI: 10.3389/fneur.2023.1132793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/02/2023] [Indexed: 02/25/2023] Open
Abstract
Cerebrospinal fluid (CSF) leakage is considered the cause of spontaneous intracranial hypotension (SIH), an important etiology for new daily persistent headaches and a potentially life-threatening condition. Minor traumatic events rarely lead to CSF leakage, contrasting with iatrogenic interventions such as a lumbar puncture or spinal surgery, which are commonly complicated by dural tears. Most meningeal lesions are found in the cervicothoracic region, followed by the thoracic region, and rarely in the lumbar region, and extremely rarely in the sacral region. We describe two patients admitted to our hospital for severe headaches aggravated in the orthostatic position, with a recent history of minor trauma and sustained physical effort, respectively. In the first case, a bone fragment pierced an incidental congenital meningocele creating a dural fistula. An extensive extradural CSF collection, spanning the cervicothoracic region (C4-T10), was described in the second case. In both patients, the clinical evolution was favorable under conservative treatment.
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Affiliation(s)
- Dana Antonescu-Ghelmez
- Department of Neurology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Neurology, National Institute of Neurology and Neurovascular Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Ioana Butnariu
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Florian Antonescu
- Department of Neurology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Neurology, National Institute of Neurology and Neurovascular Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Maier
- MedInst Romanian-German Diagnostic Center, Bucharest, Romania
| | - Adriana Moraru
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Amanda Ioana Bucur
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Daniela Nicoleta Anghel
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Sorin Tuţă
- Department of Neurology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Neurology, National Institute of Neurology and Neurovascular Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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23
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Lasunin NV, Cherekaev VA, Usachev DY, Abdullaev AN, Okishev DN, Pronin IN, Konovalov AN. [Complicated course of the postoperative period with the development of epidural hygroma and intracranial hypotension after removal of cranio-orbital meningioma. Clinical case and literature review]. Zh Vopr Neirokhir Im N N Burdenko 2023; 87:94-103. [PMID: 37830474 DOI: 10.17116/neiro20238705194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Surgical removal of cranio-orbital meningiomas is an effective method of treating this pathology. Modern surgical techniques and technologies make it possible to perform operations with a low risk of complications. Lumbar drainage or repeated lumbar punctures are often used intraoperatively or in the early postoperative period to prevent nasal CSF leak; this rarely leads to the development of significant neurological symptoms. We present a case of the development of severe intracranial hypotension with the formation of a subdural hygroma in the early postoperative period after removal of a cranio-orbital meningioma in a 41-year-old patient. The operation was performed using an individual model and molds for simultaneous reconstruction of the bone defect with an implant made of polymethyl methacrylate. On the 1st and 2nd days after surgery, lumbar punctures were performed. From the 2nd day there was a progressive deterioration with the development of symptoms characteristic of intracranial hypotension. Computed tomography revealed an increasing displacement of the midline structures of the brain and an increasing volume of epidural fluid accumulation in the area of surgical intervention. Magnetic resonance imaging revealed characteristic signs of intracranial hypotension. Conservative treatment (bed rest, active hydration) had no effect. On the 6th day after surgery, an epidural blood patch procedure was performed and closed external drainage of the epidural hygroma was performed, and a rapid regression of neurological symptoms was noted. Our experience and literature data indicate that it is necessary to remember the possibility of developing clinically significant intracranial hypotension even after a single lumbar puncture. The formation of hygromas in the surgical area is characteristic of intracranial hypotension, but in most cases does not require additional surgical intervention and does not have a negative impact on the outcome of treatment. Conservative treatment of intracranial hypotension is the first choice and often sufficient. If there is no effect and the patient's condition worsens, it is necessary to perform an epidural blood patch procedure.
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Affiliation(s)
- N V Lasunin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
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24
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M O, JK CG, I G, NR K, CM C, W B. Prevalence of cerebral vein thrombosis among patients with spontaneous intracranial hypotension. Interv Neuroradiol 2022; 28:719-725. [PMID: 34904470 PMCID: PMC9706257 DOI: 10.1177/15910199211065912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/17/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Cerebral venous sinus thrombosis (CVST) is a rare condition but an important complication of spontaneous intracranial hypotension (SIH). We reviewed our experience of patients with SIH and assessed for the presence of CVST. METHODS We reviewed the medical records and imaging studies from our tertiary referral institution, assessing patients with clinically suspected SIH as well as imaging findings of intracranial hypotension. All relevant brain MRIs were reviewed for the presence of brain sag, pachymeningeal enhancement, and CVST. RESULTS Among 563 patients with a clinical diagnosis of SIH, 431 (76%) demonstrated brain sag. In the overall patient cohort, a total of 5 patients had CVST (0.9%) and all 5 of these patients demonstrated findings of brain sag. Of the patients with CVST, 3 had significant complications, including dural arteriovenous fistulas (2 patients) and lobar hemorrhage with seizure (1 patient). CONCLUSION SIH is a risk factor for the development of CVST. In our review of 563 patients with clinical and/or imaging findings of SIH, 0.9% of patients were diagnosed with CVST and 3 of these patients (60%) had additional severe complications.
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Affiliation(s)
- Oien M
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Garza I
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Kissoon NR
- Neurology, Mayo Clinic, Rochester, MN, USA
| | - Carr CM
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Brinjikji W
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
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25
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Eley V, Keita H, Bouvet L. Epidural blood patch - still the best therapy for headaches related to intracranial hypotension. Anaesth Crit Care Pain Med 2022; 41:101139. [PMID: 35926771 DOI: 10.1016/j.accpm.2022.101139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - Hawa Keita
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation pédiatrique, Paris, France; Unité de Recherche EA 7323 Pharmacologie et Évaluation des Thérapeutiques Chez l'Enfant et la Femme Enceinte, Université de Paris, Paris, France
| | - Lionel Bouvet
- Service d'Anesthésie Réanimation, Groupement Hospitalier Est, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France; APCSe VetAgro Sup UP 2021, A101, Lyon, France.
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26
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Masourou Z, Papagiannakis N, Mantzikopoulos G, Mitsikostas DD, Theodoraki K. Treating Spontaneous Intracranial Hypotension with an Anesthetic Modality: The Role of the Epidural Blood Patch. Life (Basel) 2022; 12:life12081109. [PMID: 35892911 PMCID: PMC9331680 DOI: 10.3390/life12081109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic and therapeutic challenge; it can present with a broad clinical spectrum of symptoms, can lead to SDH and, if conservative treatment fails, an epidural blood patch (EBP) is a viable treatment option. Although the exact etiology of SIH is not known, it is believed to be due to cerebrospinal fluid (CSF) leak or a low CSF pressure. Case Series: Three patients (two males and one female) with ages ranging between 38 and 53 years old who presented with complaints of not only an orthostatic headache, but also a variety of symptoms of SIH, including the formation of two SDHs in one of them, were included in this series. These patients did not respond to conservative management and, subsequently, given the clinical and radiological evidence of SIH, were referred to the Anesthesiology Department for an EBP. Diagnostic workup was facilitated by imaging modalities, including magnetic resonance imaging (MRI) of the brain and spinal cord, prior to the EBP. All three patients were subjected to an EBP with an 18-gauge epidural needle. A total of between 30 and 43 mL of autologous blood was collected from the patients and was injected into the epidural space under strict aseptic conditions. Two lumbar (L1-L2, L2-L3) EBPs and one thoracic (T11-T12) EBP were performed on the three patients, respectively. All patients reported complete resolution of symptoms following the EBPs, while MRI improved substantially. Conclusions: This report describes three cases of SIH with CSF leak originating from the cervical, the thoracic and the lumbar level. The EBP restored CSF pressure and relieved the patients' persistent symptoms. MRI helps in revealing indirect signs of a low volume of CSF, though it may not be possible to locate the actual site of the leak. In conclusion, EBP is a well-accepted and beneficial treatment modality for SIH when conventional measures fail.
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Affiliation(s)
- Zoi Masourou
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Nikolaos Papagiannakis
- Department of Neurology, Aiginiteion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (N.P.); (D.-D.M.)
| | | | - Dimos-Dimitrios Mitsikostas
- Department of Neurology, Aiginiteion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (N.P.); (D.-D.M.)
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Correspondence:
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Miano DI, Byrd G, Kattoula R, Thet A, Adkins R, Cosgrove R, Johnson SS. Acute Enophthalmos After Lumbar Puncture in a Patient with Type 1 Neurofibromatosis Related Sphenoid Wing Dysplasia. Neuroophthalmology 2022; 46:270-274. [PMID: 35859630 PMCID: PMC9291671 DOI: 10.1080/01658107.2022.2034891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
A 19-year-old woman with type 1 neurofibromatosis related sphenoid wing dysplasia underwent a lumbar puncture (LP) after an unexplained syncopal event. The cerebrospinal fluid work-up was unremarkable. However, 30-hours post LP, she developed marked enophthalmos ipsilateral to the calvarial dysplasia. The enophthalmos gradually resolved within 72 hours. We surmise that the patient's enophthalmos was due to an LP induced decrease of intracranial pressure in conjunction with the orbital bone anomaly.
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Affiliation(s)
- Deanna Ingrassia Miano
- Department of Ophthalmology, Ascension Macomb-Oakland Hospital, Warren, Michigan, USA,CONTACT Deanna Ingrassia Miano Ascension Macomb-Oakland Hospital, 11800 Twelve Mile Rd, Warren, MI 48093
| | - Gregory Byrd
- Department of Internal Medicine, Ascension Macomb-Oakland Hospital, Warren, Michigan, USA
| | - Rani Kattoula
- Department of Internal Medicine, Ascension Macomb-Oakland Hospital, Warren, Michigan, USA
| | - Aye Thet
- Department of Internal Medicine, Ascension Macomb-Oakland Hospital, Warren, Michigan, USA
| | - Ryan Adkins
- Department of Emergency Medicine, Ascension Macomb-Oakland Hospital, Warren, Michigan, USA
| | - Ryan Cosgrove
- Department of Ophthalmology, Ascension Macomb-Oakland Hospital, Warren, Michigan, USA
| | - Samantha S. Johnson
- Department of Ophthalmology, Ascension Macomb-Oakland Hospital, Warren, Michigan, USA
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Liang X, Yang X, Liang S, Zhang Y, Ding Z, Guo Q, Huang C. Effect of Intravenous Ketamine on Hypocranial Pressure Symptoms in Patients with Spinal Anesthetic Cesarean Sections: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:4129. [PMID: 35887893 DOI: 10.3390/jcm11144129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 12/22/2022] Open
Abstract
Background: Pregnant women are more likely to suffer post-puncture symptoms such as headaches and nausea due to the outflow of cerebrospinal fluid after spinal anesthesia. Because ketamine has the effect of raising intracranial pressure, it may be able to improve the symptoms of perioperative hypocranial pressure and effectively prevent the occurrence of hypocranial pressure-related side effects. Method: Keywords such as ketamine, cesarean section, and spinal anesthesia were searched in databases including Medline, Embase, Web of Science, and Cochrane from 1976 to 2021. Thirteen randomized controlled trials were selected for the meta-analysis. Results: A total of 12 randomized trials involving 2099 participants fulfilled the inclusion criteria. There was no significant association between ketamine and the risk of headaches compared to the placebo (RR = 1.12; 95% CI: 0.53, 2.35; p = 0.77; I² = 62%). There was no significant association between ketamine and nausea compared to the placebo (RR = 0.66; 95% CI: 0.40, 1.09; p = 0.10; I² = 57%). No significant associations between ketamine or the placebo and vomiting were found (RR = 0.94; 95% CI: 0.53, 1.67; p = 0.83; I² = 72%). Conclusion: Intravenous ketamine does not improve the symptoms caused by low intracranial pressure after spinal anesthesia in patients undergoing cesarean section.
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Fearon C, Rawal S, Olszewska D, Alcaide‐Leon P, Kern DS, Sharma S, Jaiswal SK, Murthy JM, Ha AD, Schwartz RS, Fung VS, Spears C, Tholanikunnel T, Almeida L, Hatano T, Oji Y, Hattori N, Shubham S, Kumar H, Bhidayasiri R, Laohathai C, Lang AE. Neuroimaging Pearls from the MDS Congress Video Challenge. Part 2: Acquired Disorders. Mov Disord Clin Pract 2022; 9:311-325. [PMID: 35402651 PMCID: PMC8974867 DOI: 10.1002/mdc3.13415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 02/05/2023] Open
Abstract
The MDS Video Challenge continues to be the one of most widely attended sessions at the International Congress. Although the primary focus of this event is the presentation of complex and challenging cases through videos, a number of cases over the years have also presented an unusual or important neuroimaging finding related to the case. We reviewed the previous Video Challenge cases and present here a selection of those cases which incorporated such imaging findings. We have compiled these "imaging pearls" into two anthologies. The first focuses on pearls where the underlying diagnosis was a genetic condition. This second anthology focuses on imaging pearls in cases where the underlying condition was acquired. For each case we present brief clinical details along with neuroimaging findings, the characteristic imaging findings of that disorder and, finally, the differential diagnosis for the imaging findings seen.
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Affiliation(s)
- Conor Fearon
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital–UHN, Division of NeurologyUniversity of TorontoTorontoOntarioCanada
| | - Sapna Rawal
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western HospitalUniversity Health NetworkTorontoOntarioCanada
| | - Diana Olszewska
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital–UHN, Division of NeurologyUniversity of TorontoTorontoOntarioCanada
| | - Paula Alcaide‐Leon
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western HospitalUniversity Health NetworkTorontoOntarioCanada
| | - Drew S. Kern
- Department of Neurology and NeurosurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Soumya Sharma
- Department of Clinical Neurological Sciences, London Health Sciences CentreWestern UniversityLondonOntarioCanada
| | | | | | - Ainhi D. Ha
- Movement Disorders UnitWestmead HospitalWestmeadNew South WalesAustralia
| | - Raymond S. Schwartz
- Southern NeurologyKoharahNew South WalesAustralia,Sydney Medical SchoolThe University of SydneyCamperdownNew South WalesAustralia
| | - Victor S.C. Fung
- Movement Disorders UnitWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolThe University of SydneyCamperdownNew South WalesAustralia
| | - Chauncey Spears
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Tracy Tholanikunnel
- Department of Neurology, Normal Fixel Institute for Neurological DiseasesUniversity of FloridaGainesvilleFloridaUSA
| | - Leonardo Almeida
- Department of Neurology, Normal Fixel Institute for Neurological DiseasesUniversity of FloridaGainesvilleFloridaUSA
| | - Taku Hatano
- Department of Neurology, Faculty of Medicine, Juntendo UniversityTokyoJapan
| | - Yutaka Oji
- Department of Neurology, Faculty of Medicine, Juntendo UniversityTokyoJapan
| | - Nobutaka Hattori
- Department of Neurology, Faculty of Medicine, Juntendo UniversityTokyoJapan
| | | | | | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross SocietyBangkokThailand,The Academy of Science, The Royal Society of ThailandBangkokThailand
| | | | - Anthony E. Lang
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital–UHN, Division of NeurologyUniversity of TorontoTorontoOntarioCanada
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Zhang D, Chen Y, Wang J, Hu X. Intracranial hypotension as a contributor to isolated cortical vein thrombosis. Headache 2022; 62:212-219. [PMID: 35137399 DOI: 10.1111/head.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Isolated cortical vein thrombosis (ICVT), a rare type of cerebral venous thrombosis (CVT), is diagnostically challenging in some cases, and intracranial hypotension (IH) is known to cause CVT. METHODS In this study, we reviewed the clinical and imaging characteristics of ICVT in patients with IH caused by spinal cerebrospinal fluid leakage, based on a literature review and investigation of cases from our hospital. RESULTS Between January 1, 2007, and November 1, 2019, 735 patients were diagnosed with IH at our hospital; three patients developed ICVT (incidence ~ 0.4%, 3/735), and the literature review yielded an additional 23 cases. Therefore, 26 patients (mean age 35.9 ± 11.4 years old) were included in this study. The most common symptoms were headache (100.0%, 26/26), focal neurological deficits (53.8%, 14/26), and seizure (34.6%, 9/26). The initial headache was orthostatic in 96.2% (25/26) of patients, and 38.5% (10/26) of patients reported a change in the headache pattern following diagnosis of ICVT. Neuroimaging findings associated with ICVT included the cord sign (61.5%, 16/26) and parenchymal brain lesions (46.2%, 12/26), such as intracerebral hemorrhage (30.8%, 8/26), hemorrhagic infarcts (11.5%, 3/26), and localized edema (11.5%, 3/26). The percentage of patients who received anticoagulation and epidural blood patch therapy was similar (69.2% [18/26] vs. 65.4% [17/26]), and most patients recovered completely (92.3%, 24/26). CONCLUSION IH should be considered in the differential diagnosis in patients with ICVT. Knowledge of the relevant clinical and neuroimaging features is important to facilitate early diagnosis for favorable prognosis.
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Affiliation(s)
- Dan Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Yin Chen
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Jin Wang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Xingyue Hu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
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Fernando EZ, Jamora RDG, Torio EF, Mariano MM, Cuanang JR, de Guzman VE. Acute Subdural Hemorrhage as the Initial Presentation of Intracranial Hypotension Following Cervical Chiropractic Manipulation: A Case Report and Systematic Review. Neurohospitalist 2022; 12:57-62. [PMID: 34950387 PMCID: PMC8689553 DOI: 10.1177/1941874420977767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) still remains an underdiagnosed etiology of new-onset headache. Important risk factors include chiropractic manipulation (CM). We present a case of a 36-year-old Filipino woman who presented with severe bifrontal and postural headache associated with dizziness, vomiting, and doubling of vision. A cranial computed tomography scan was done which showed an acute subdural hematoma (SDH) at the interhemispheric area. Pain medications were given which afforded minimal relief. On history, the headaches occurred 2 weeks after cervical CM. Cranial and cervical magnetic resonance imaging revealed findings supportive of intracranial hypotension and neck trauma, respectively. The patient improved with conservative management. We found 12 articles on SIH and CM after a systematic review of literature. Eleven patients (90.9%) initially presented with orthostatic headache. Eight patients (66.7%) were initially treated conservatively but only 5 (62.5%) had complete recovery. Recovery was achieved within 14 days from start of supportive therapy. Among the 3 patients who failed conservative treatment, 2 underwent non-directed epidural blood patch and one required neurosurgical intervention. This report highlights that a thorough history is warranted in patients with new onset headache. A history of CM must be actively sought. The limited evidence from the case reports showed that patients with SIH and SDH but with normal neurologic examination and minor spinal pathology can be managed conservatively for less than 2 weeks. This review showed that conservative treatment in a closely monitored environment may be an appropriate first line treatment.
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Affiliation(s)
- Emmaline Z. Fernando
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City, Philippines
| | - Roland Dominic G. Jamora
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines,Division of Adult Neurology, Department of Neurosciences, College of Medicine - Philippine General Hospital, University of the Philippines Manila, Manila, Philippines,Roland Dominic G. Jamora, Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines and Division of Adult Neurology, Department of Neurosciences, College of Medicine - Philippine General Hospital, University of the Philippines Manila, Manila, Philippines. Emails: ;
| | - Erickson F. Torio
- Section of Neurosurgery, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
| | - Manuel M. Mariano
- Section of Neurosurgery, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
| | - Joven R. Cuanang
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
| | - Vincent E. de Guzman
- Section of Neurology, Institute for Neurosciences, St. Luke’s Medical Center, Quezon City & Global City, Philippines
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Li B, Ng C, Feldstein E, Muh C, Mohan A, Tobias M. Non-Operative Management of a Pediatric Patient With Bilateral Subdural Hematomas in the Setting of Ruptured Arachnoid Cyst. Cureus 2021; 13:e20099. [PMID: 34873561 PMCID: PMC8637768 DOI: 10.7759/cureus.20099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/11/2022] Open
Abstract
Pediatric subdural hematomas (SDH) are associated with arachnoid cysts (AC), particularly in the middle cranial fossa (MCF). Operative management of these hemorrhages is a mainstay of treatment. Conservative management may be an option if there is minimal mass effect and the patient is mildly symptomatic. A 14-year-old male presented with right frontal headaches that worsened with activity. He was found to have a large right MCF AC. Scheduled routine outpatient follow-up CT of the head demonstrated bilateral SDH. There was no history of significant head trauma. He was admitted for close observation and his inpatient scans remained stable. Outpatient follow-up imaging over the course of three and a half years demonstrated resolution of SDH and decreased AC size. He denied headaches and continued doing well in school. ACs are a risk factor for the development of SDH in young male patients after minor trauma. Development of intracranial hypotension secondary to AC rupture may have contributed to the development of bilateral SDH in our patient. We demonstrate here that close clinical follow up with serial imaging may be considered a management strategy in these patients.
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Affiliation(s)
- Boyi Li
- Neurological Surgery, University of North Carolina at Chapel Hill School of Medicine, Valhalla, USA
| | - Christina Ng
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Eric Feldstein
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Carrie Muh
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Avinash Mohan
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Michael Tobias
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
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Yıldırım F, Turan A, Güven S, Akdağ T. Absence of CSF flow within the cerebral aqueduct in spontaneous intracranial hypotension: a report of two cases. Br J Neurosurg 2021:1-4. [PMID: 34796783 DOI: 10.1080/02688697.2021.2006141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 08/10/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is a potentially debilitating condition resulting from a low cerebrospinal fluid (CSF) volume secondary to spinal CSF leakage. Characteristic clinical and radiological imaging findings are helpful in diagnosis. Herein, we present and discuss the magnetic resonance imaging (MRI) and CSF flow study of two patients with SIH and no CSF flow within the cerebral aqueduct, which is extremely rare in the literature.
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Affiliation(s)
- Ferhat Yıldırım
- Radiology Department, Diskapi Yildirim Beyazit Health Application and Research Center, University of Health Sciences, Ankara, Turkey
| | - Aynur Turan
- Radiology Department, Diskapi Yildirim Beyazit Health Application and Research Center, University of Health Sciences, Ankara, Turkey
| | - Selda Güven
- Radiology Department, Diskapi Yildirim Beyazit Health Application and Research Center, University of Health Sciences, Ankara, Turkey
| | - Tuba Akdağ
- Radiology Department, Diskapi Yildirim Beyazit Health Application and Research Center, University of Health Sciences, Ankara, Turkey
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Abstract
Background Spontaneous intracranial hypotension (SIH) is a highly misdiagnosed and underdiagnosed disorder. Objective Update evaluation and treatment of spontaneous intracranial hypotension. Methods and Material Narrative review. Results Traditionally, SIH is diagnosed when a headache has developed spontaneously and in temporal relation to a CSF leak (evident on imaging) and/or CSF hypotension (lumbar puncture opening pressure <60 mm CSF). However, lumbar puncture is not mandatorily required to diagnose SIH. Besides headache, other symptoms such as nausea/vomiting in 50.6%, neck pain/stiffness in 33%, tinnitus in 19%, dizziness in 14%, hearing disturbances in 10.7%, followed by visual disturbances, vertigo, back pain, and cognitive symptoms may be present. In suspected cases of SIH, brain and spine should be evaluated with MRI. Dynamic computerized tomographic myelography is required to demonstrate the site of spinal CSF leak. Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH) refractory to medical management and provides symptomatic relief in up to 90% of patients even in patients with bilateral subdural hematomas. The CSF-venous fistulas do not respond well to EBP, and the most definitive curative treatment is the surgical closure of the fistula. Conclusions The SIH is a distinct entity and requires a high index of suspicion for diagnosis. A post-contrast MRI should be included for evaluation of headaches. Spinal MRI should be done to demonstrate the site of leak. Epidural blood patch therapy is the most effective treatment of SIH. Most SDHs associated with SIH do not require treatment.
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Affiliation(s)
- Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Jitender Saini
- Department of Neuroradiology and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sriganesh Kamath
- Department of Neuroanesthesiology and Neuro Critical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Darwish A, Alserihy O, Brinji Z, Rawah E, Elsodany I. Posterior Reversible Encephalopathy Syndrome Following Intracranial Hypotension Due to Cerebrospinal Fluid (CSF) Leakage: A Report of Two Cases. Cureus 2021; 13:e17841. [PMID: 34660048 PMCID: PMC8501469 DOI: 10.7759/cureus.17841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/30/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) in cases of intracranial hypotension is a life-threatening condition. Early suspicion, appropriate treatment, and tight control of possible contributing factors that may facilitate PRES in cerebrospinal fluid (CSF) leak patients may bring a more favorable outcome, lowering the morbidity and mortality rate. Two cases of PRES with features of intracranial hypotension are presented. We also discussed the possible pathogenesis of PRES in patients with intracranial hypotension. We emphasize the importance of the early diagnosis and treatment of ICH by repairing the leakage and further prompt attention to tight blood pressure control in those patients to avoid PRES development.
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Affiliation(s)
- Abdullah Darwish
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Omar Alserihy
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Zaina Brinji
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Elham Rawah
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Ibrahim Elsodany
- Department of Internal Medicine, King Abdullah Medical City, Makkah, SAU
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Radu RA, Terecoasa EO, Marinescu AN, Enache I, Tiu C. Cranial cerebrospinal fluid leak and intracranial hypotension syndrome - a case report. J Med Life 2021; 14:587-590. [PMID: 34621386 PMCID: PMC8485374 DOI: 10.25122/jml-2021-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/16/2021] [Indexed: 11/17/2022] Open
Abstract
Spontaneous intracranial hypotension is a rare clinical entity caused in most cases by a cerebrospinal fluid leak occurring at the level of the spinal cord. Cranial dural leaks have been previously reported as a cause of orthostatic headaches but, as opposed to spinal dural leaks, were not associated with other findings characteristic of spontaneous intracranial hypotension. We present the case of a male admitted for severe orthostatic headache. The patient had a history of intermittent postural headaches, dizziness, and symptoms consistent with post-nasal drip, which appeared several years after head trauma. Brain imaging showed signs consistent with intracranial hypotension: bilateral hygromas, subarachnoid hemorrhage, superficial siderosis, diffuse contrast enhancement of the pachymeninges, and superior sagittal sinus engorgement. No spinal leak could be identified by magnetic resonance imaging, and the patient had a rapid remission of symptoms with conservative management. Further work-up identified an old temporal bone fracture which created a route of egress between the posterior fossa and the mastoid cells. Otorhinolaryngology examination showed pulsatile bloody discharge and liquorrhea at the level of the left pharyngeal opening of the Eustachian tube. The orthostatic character of the headache, as well as the brain imaging findings, were consistent with intracranial hypotension syndrome caused by a cranial dural leak. Clinical signs and imaging findings consistent with the diagnosis of apparently “spontaneous” intracranial hypotension should prompt the search for a cranial dural leak if a spinal leak is not identified.
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Affiliation(s)
- Razvan Alexandru Radu
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Neurology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Elena Oana Terecoasa
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Neurology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Nicoleta Marinescu
- Department of Radiology and Medical Imaging, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Radiology and Medical Imaging, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Iulian Enache
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Cristina Tiu
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Neurology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Cheng SJ, Hakkinen I, Zhang P, Roychowdhury S. Paradoxical headache in a case of chronic spontaneous intracranial hypotension and multiple perineural cysts. Headache 2021; 61:1291-1294. [PMID: 34510443 DOI: 10.1111/head.14188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Samantha J Cheng
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ian Hakkinen
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Pengfei Zhang
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sudipta Roychowdhury
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Abstract
BACKGROUND In 2013, one of the authors described a 36-year-old female with orthostatic headache without documented intracranial hypotension or evidence of cerebrospinal fluid leak, despite extensive workup. Headache was unresponsive to conservative treatment since 2010, showed only transient benefit after repeated epidural blood patches while vitamin A supplementation resulted in progressive improvement. CASE Since 2013, the patient followed a relapsing and remitting course yet relapse control became difficult after a drug induced liver injury required vitamin A discontinuation in 2017, when her headache became chronic. Greater occipital nerve blocks provided pain relief as alternative but were stopped due to the pandemic and her latest severe relapse, in late 2020, required not only restarting anaesthetic blocks and aggressive medication management, but also reassessing and treating comorbidities (obstructive sleep apnoea and major depressive disorder) with modest benefit. CONCLUSION Orthostatic headache without intracranial hypotension is rare, with only 28 cases reported so far, all treated empirically and all treatment options revealing to be mostly ineffective. Vitamin A anecdotally appeared to be useful in our case but had to be stopped for severe side effects, so unfavourable long-term prognosis, in ours and 2/3 of the reported cases, seems to be the rule in this intriguing entity.
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Wnuk E, Maj E, Dziedzic T, Podlecka Piętowska A. Spinal Epidural Venous Plexus Enlargement as a Cause of Neurologic Symptoms: Vascular Anatomy and MRI Findings. Neurol India 2021; 68:1238-1241. [PMID: 33109888 DOI: 10.4103/0028-3886.294546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Pathology of the spinal venous system, unlike that of the spinal arterial system, is rarely considered as a possible cause of clinical symptoms. As the imaging features of the spinal venous anatomy and its diseases are not well-known, related pathologies may be overlooked or misdiagnosed. The major noninvasive technique enabling optimal visualization of spinal venous plexuses is magnetic resonance imaging (MRI). We report MRI findings from three cases of spinal venous plexus engorgement of different etiologies that resulted in neurologic symptoms, including radiculopathy and/or back pain. These cases are discussed in the context of the relevant anatomic and pathophysiologic background.
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Affiliation(s)
- Emilia Wnuk
- Second Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Edyta Maj
- Second Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Redon S, Elzière M, Donnet A. The neurologist and the hydrops. J Vestib Res 2021; 31:303-309. [PMID: 33843710 DOI: 10.3233/ves-200790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The presence of endolymphatic hydrops has been studied in many neurological disorders. The pathophysiological mechanisms may involve CSF pressure variations, transmitted to the innear ear. This hydrops could play a role in vestibular or cochlear symptoms. For the ENT specialist, the etiological diagnosis of endolymphatic hydrops is a challenge, and neurological etiologies must be known. The treatment of these neurological causes could be effective on cochleo-vestibular symptoms. The knowledge of endolymphatic hydrops could also be a target for noninvasive tests, able to estimate CSF pressure variations. For the neurologist, this could represent a useful tool for the diagnosis and follow-up, in some of these neurological disorders, related to a CSF pressure imbalance. The purpose of this paper is to summarize literature data on endolymphatic hydrops in neurological disorders. We define some neurological conditions, for which there is a particular interest in noninvasive investigations of endolymphatic hydrops.
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Affiliation(s)
- Sylvain Redon
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, CHU Timone, AP-HM, Marseille, France
| | - Maya Elzière
- Vertigo center, European Hospital, Marseille, France
| | - Anne Donnet
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, CHU Timone, AP-HM, Marseille, France.,INSERM U-1107, CHU de Clermont-Ferrand, Clermont-Ferrand, France
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Chang W, Kadribegic A, Denham K, Kulzer M, Tragon T, Weis T, Spearman M, Goldberg M. Incidence of postural headache after lumbar puncture requiring epidural blood patch: Effects of needle caliber; 2-year experience. Neuroradiol J 2021; 34:418-420. [PMID: 33678066 DOI: 10.1177/19714009211000630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE A common complication of lumbar puncture (LP) is postural headaches. Epidural blood patches are recommended if patients fail conservative management. Owing to a perceived increase in the number of post-lumbar puncture headaches (PLPHs) requiring epidural blood patches at a regional hospital in our network, the decision was made to switch from 20 to 22 gauge needles for routine diagnostic LPs. MATERIALS AND METHODS Patients presenting for LP and myelography at one network regional hospital were included in the study. The patients were contacted by nursing staff 3 days post-procedure; those patients who still had postural headaches after conservative management and received epidural blood patches were considered positive cases. In total, 292 patients were included; 134 underwent LP with 20-gauge needles (53 male, 81 female, average age 57.7) and 158 underwent LP with 22-gauge needles (79 male, 79 female, average age 54.6). RESULTS Of 134 patients undergoing LP with 20-gauge needles, 15 (11%) had PLPH requiring epidural blood patch (11 female, 3 male, average age 38). Of 158 patients undergoing LP with 22-gauge needles, only 5 (3%) required epidural blood patches (all female, average age 43). The difference was statistically significant (p < 0.01). Risk factors for PLPH included female gender, younger age, lower body mass index, history of prior PLPH and history of headaches. CONCLUSION Switching from 20-gauge to 22-gauge needles significantly decreased the incidence of PLPH requiring epidural blood patch. Narrower gauge or non-cutting needles should be considered in patients with risk factors for PLPH, allowing for CSF requirements.
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Affiliation(s)
- Warren Chang
- Department of Radiology, Allegheny Health Network, USA
| | | | - Kate Denham
- Department of Radiology, Allegheny Health Network, USA
| | | | - Tyson Tragon
- Department of Radiology, Allegheny Health Network, USA
| | - Ty Weis
- Department of Anesthesia, Allegheny Health Network, USA
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Magyar M, Nyilas NL, Bereczki D, Bozsik G, Rudas G, Ertsey C, Maurovich-Horvat P, Barsi P. Evaluation and diagnosis of spontaneous intracranial hypotension with magnetic resonance imaging. Orv Hetil 2021; 162:246-251. [PMID: 33582651 DOI: 10.1556/650.2021.31961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022]
Abstract
Összefoglaló. A klasszikus esetben ortosztatikus fejfájást okozó, spontán intracranialis hypotensiót az esetek túlnyomó többségében a gerinccsatornában, annak nyaki-háti átmenetében, illetve a háti szakaszán található liquorszivárgás okozza. Meglévő kötőszöveti betegség, degeneratív gerincbetegségek, illetve kisebb traumák szerepet játszhatnak a szivárgás kialakulásában. Az ortosztatikus fejfájás létrejöttében szerepet játszhat a meningealis szerkezetek, érzőidegek és hídvénák vongálódása. A klasszikus pozicionális, ortosztatikus fejfájásban szenvedő betegek körében gondolni kell a spontán intracranialis hypotensio lehetőségére, és az agykoponya, illetve a gerinc kontrasztanyaggal végzett mágneses rezonanciás vizsgálata (MRI) javasolt. A kontrasztanyaggal végzett koponya-MRI-vel klasszikus esetben diffúz, nem nodularis, intenzív, vaskos pachymeningealis kontrasztanyag-halmozás, kitágult vénássinus-rendszer, subduralis effusiók és az agytörzs caudalis diszlokációja ("slumping") látható. Fontos azonban szem előtt tartani, hogy az esetek 20%-ában ezen eltérések nem detektálhatók. Jó minőségű, randomizált, kontrollált vizsgálatok nem történtek, a kezelés hagyományokon alapul. Kezdetben általában konzervatív terápiát alkalmaznak (ágynyugalom, koffein- és folyadékbevitel), ennek hatástalansága esetén epiduralis sajátvér-injekció, epiduralis fibrinragasztó-injektálás, illetve sebészi terápia jöhet szóba. Orv Hetil. 2021; 162(7): 246-251. Summary. Spontaneous intracranial hypotension, the classic feature of which is orthostatic headache, is most commonly caused by a cerebrospinal fluid leakage at the level of the spinal canal, in most cases at the thoracic level or cervicothoracic junction. Underlying connective tissue disorders, minor trauma, degenerative spinal diseases may play a role in the development of cerebrospinal fluid leaks. Traction on pain-sensitive intracranial and meningeal structures, particularly sensory nerves and bridging veins, may play a role in the development of orthostatic headache. In the case of patients with classic orthostatic headache, the possibility of spontaneous intracranial hypotension should be considered, and if suspected, brain magnetic resonance imaging (MRI) with gadolinium and additional spine MRI are recommended. Diffuse, non-nodular, intense, thick dural enhancement, subdural effusions, engorgement of cerebral venous sinuses, sagging of the brain are typical features on brain MRI, which, however, remain normal in up to 20 percent of patients with spontaneous intracranial hypotension. Unfortunately, no randomized clinical trials have evaluated the effectiveness of the various treatment strategies and no definitive treatment protocols have been established. In clinical practice, the first-line treatment of spontaneous intracranial hypotension is conservative (bed rest, caffeine and fluid intake). If conservative therapy is not effective, epidural blood patch, epidural fibrin glue, or surgical repair should be considered. Orv Hetil. 2021; 162(7): 246-251.
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Affiliation(s)
- Máté Magyar
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Neurológiai Klinika, Budapest, Balassa J. u. 6., 1083.,2 Semmelweis Egyetem, Szentágothai János Idegtudományi Doktori Iskola, Budapest.,3 Semmelweis Egyetem, Általános Orvostudományi Kar, Orvosi Képalkotó Klinika, Neuroradiológia Tanszék, Budapest
| | - Nóra Luca Nyilas
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Orvosi Képalkotó Klinika, Neuroradiológia Tanszék, Budapest
| | - Dániel Bereczki
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Neurológiai Klinika, Budapest, Balassa J. u. 6., 1083
| | - György Bozsik
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Neurológiai Klinika, Budapest, Balassa J. u. 6., 1083
| | - Gábor Rudas
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Orvosi Képalkotó Klinika, Neuroradiológia Tanszék, Budapest
| | - Csaba Ertsey
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Neurológiai Klinika, Budapest, Balassa J. u. 6., 1083
| | - Pál Maurovich-Horvat
- 4 Semmelweis Egyetem, Általános Orvostudományi Kar, Orvosi Képalkotó Klinika, Radiológia Tanszék, Budapest
| | - Péter Barsi
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Orvosi Képalkotó Klinika, Neuroradiológia Tanszék, Budapest
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Nagesh CP, Devaraj R, Joshi G, Shafi P, Krishna KN, Satischandra P. The importance of repeat digital subtraction myelography in the diagnosis of cryptogenic CSF-venous fistula causing spontaneous intracranial hypotension. Interv Neuroradiol 2021; 27:727-732. [PMID: 33525918 DOI: 10.1177/1591019921991398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a rare disorder that occurs secondary to acquired cerebrospinal fluid (CSF) leaks in the spine. Treatment involves either an epidural blood patch or surgical ligation. Essential to the selecting the optimal management strategy is classifying the type of leak and accurate localization of its level. Hitherto, this has been achieved using conventional imaging methods such as static CT or MR myelography which are adequate for the demonstration of only high flow leaks. Digital subtraction myelography (DSM) is a novel technique which provides superior temporal and spatial resolution in the localization of more challenging slow flow leaks. However, DSM may also be initially non-diagnostic. We report a case of SIH in which repeat DSM revealed a type 3 CSF-venous fistula and demonstrate a possible mechanism of transient CSF leak block resulting in the initial false negative findings based on morphological changes in the culprit nerve sheath diverticulum-pseudomeningocoele complex. The patient underwent successful surgical ligation with clinicoradiological resolution of SIH.
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Affiliation(s)
- Chinmay P Nagesh
- Department of Neuroendovascular and Interventional Radiology, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - Rashmi Devaraj
- Department of Neurology, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - Girish Joshi
- Department of Neurosurgery, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - Peerzada Shafi
- Department of Neurology, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
| | - K N Krishna
- Department of Neurosurgery, Institute of Neurosciences, Apollo Speciality Hospital, Bangalore, India
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Bevacqua M, Abbracciavento G, Murru FM, Barbi E. A 16-year-old boy with a headache, back neck pain and positional vertigo. Arch Dis Child Educ Pract Ed 2021; 106:44-46. [PMID: 31320379 DOI: 10.1136/archdischild-2019-316831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/18/2019] [Indexed: 11/03/2022]
Affiliation(s)
| | | | | | - Egidio Barbi
- University of Trieste, Trieste, Italy.,Institute for Maternal and Child Health, Trieste, Italy
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Wawrose RA, Dombrowski ME, Crasto JA, Shaw JD, Lee JY. Chronic Subdural Hematoma as a Complication of Cerebrospinal Fluid Leak During Revision Lumbar Spine Surgery: A Case Report and Review of the Literature. HSS J 2020; 16:482-4. [PMID: 33380983 DOI: 10.1007/s11420-019-09709-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/02/2019] [Indexed: 02/07/2023]
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Osada Y, Shibahara I, Nakagawa A, Sakata H, Niizuma K, Saito R, Kanamori M, Fujimura M, Suzuki S, Tominaga T. Unilateral chronic subdural hematoma due to spontaneous intracranial hypotension: a report of four cases. Br J Neurosurg 2020; 34:632-637. [PMID: 31535558 DOI: 10.1080/02688697.2019.1667482] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/18/2019] [Accepted: 09/10/2019] [Indexed: 10/26/2022]
Abstract
Background: Chronic subdural hematoma (CSDH) is a common neurosurgical disease. A subset of patients with CSDH may exhibit underlying spontaneous intracranial hypotension (SIH). Bilateral CSDH has a causal relationship with SIH, but there is no known causal relationship between unilateral CSDH and SIH.Case description: We encountered four cases of unilateral CSDH due to SIH. The patients' age ranged between 44 and 64 years; there were three males and one female. All patients presented with headache as their initial symptom, and then became comatose. Computed tomography demonstrated unilateral CSDH and transtentorial herniation in all patients. Treatments were emergency epidural blood patch (EBP) and evacuation of CSDH. The site of cerebrospinal fluid leak could not be identified in three patients; therefore, EBP was performed at upper and lower spine. All patients recovered from SIH; however, one patient experienced poor outcome due to Duret hemorrhage and ischemic complications of transtentorial herniation. Cranial asymmetry was present in all four patients, and unilateral CSDH was located on the side of the most curved cranial convexity.Conclusions: Unilateral CSDH, asymmetric cranial morphology, and transtentorial herniation in relatively young patients may indicate underlying SIH.
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Affiliation(s)
- Yoshinari Osada
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ichiyo Shibahara
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsuhiro Nakagawa
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyuki Sakata
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masayuki Kanamori
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shinsuke Suzuki
- Department of Neurosurgery, Sendai Medical Center, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Uchigami H, Seki T, Hideyama T, Katsumata J, Maekawa R, Shiio Y. Spontaneous Intracranial Hypotension with a Reversible Splenial Lesion after Swimming. Intern Med 2020; 59:2593-2596. [PMID: 32581170 PMCID: PMC7662063 DOI: 10.2169/internalmedicine.4971-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is an important cause of headache mainly associated with spinal cerebrospinal fluid leakage. We herein report the case of a 51-year-old man who developed SIH after swimming. Brain magnetic resonance imaging (MRI) showed a transient high-intensity lesion in the splenium of the corpus callosum (SCC), in addition to bilateral subdural hematomas (SDH) and pseudo-subarachnoid hemorrhage on brain computed tomography. The splenial lesion disappeared and SDH improved after an epidural blood patch. This case emphasizes that transient SCC lesions could coexist with SIH and that SIH should be considered in the differential diagnosis of SCC lesions.
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Affiliation(s)
| | - Tomonari Seki
- Department of Neurology, Tokyo Teishin Hospital, Japan
| | | | | | - Risa Maekawa
- Department of Neurology, Tokyo Teishin Hospital, Japan
| | - Yasushi Shiio
- Department of Neurology, Tokyo Teishin Hospital, Japan
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Paris D, Rousset D, Bonneville F, Fabre N, Faguer S, Huguet-Rigal F, Larcher C, Martin C, Osinski D, Gaussiat F, Delamarre L, Brauge D, Fourcade O, Geeraerts T, Mrozek S. Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report. Headache 2020; 60:2583-2588. [PMID: 32990351 DOI: 10.1111/head.13977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH. METHODS Case report. CASE DESCRIPTION We report here a case of comatose patient due to spontaneous IH complicated by CVT and subdural hemorrhage. The correct diagnosis was delayed due to many confounding factors. IH was suspected after subdural hemorrhage recurrence and confirmed by magnetic resonance imaging (MRI). After 2 epidural patches with colloid, favorable outcome was observed. DISCUSSION The most common presentation of IH is postural orthostatic headaches. In the present case report, the major clinical signs were worsening of consciousness and coma, which are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within the brain. CONCLUSION Association of CVT and subdural hemorrhage should lead to suspect IH. Brain imaging can help and find specific signs of IH.
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Affiliation(s)
- Diane Paris
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - David Rousset
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Fabrice Bonneville
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Nelly Fabre
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Stanislas Faguer
- Department of Nephrology, Dialysis and Multi-Organ Transplantation, Toulouse University Hospital, Toulouse, France
| | - Françoise Huguet-Rigal
- Department of Hematology, University Institute of Cancer of Toulouse-Oncopole, Toulouse, France
| | - Claire Larcher
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Charlotte Martin
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Diane Osinski
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - François Gaussiat
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Louis Delamarre
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - David Brauge
- Department of Neurosurgery, University Hospital of Toulouse, Toulouse, France
| | - Olivier Fourcade
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Ségolène Mrozek
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
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Abstract
Intracranial hypotension can be a common sequela of a cerebrospinal fluid (CSF) leak. However, evidence of such a condition related to an injury in American football is currently lacking in the literature. While a positional or orthostatic headache is the most classic symptom of headaches due to intracranial hypotension, a variety of nonspecific symptoms such as neck pain, nausea, vomiting, photophobia, phonophobia, and visual changes can also be present. We present two cases where collegiate American football players developed protracted headaches after a concussive injury and were subsequently diagnosed with intracranial hypotension thought secondary to spinal CSF leaks. Both players underwent multiple procedures of fluoroscopic-guided autologous blood patching, with improvement in their headaches. Recovery varied between the athletes. Case 1 achieved full resolution of his headaches and returned to full activity. Case 2 continued to have intermittent headaches after blood patching, but the positional nature had resolved and he was cleared for full participation in football and was closely followed during the remainder of his collegiate career. Both these cases emphasize the importance of including CSF leak as a cause of post-traumatic headache in an American football player.
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Affiliation(s)
| | - Robert M Donlan
- Sports Medicine, DCH Center for Occupational Health, Tuscaloosa, USA
| | - John Breck
- Sports Medicine, University of Colorado, Boulder, USA
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