Clinical Presentation, Investigation Findings, and Treatment Outcomes of Spontaneous Intracranial Hypotension Syndrome: A Systematic Review and Meta-analysis

Exploratory operation in a patient with spontaneous temporal bone cerebrospinal fluid leaks: A case report

BACKGROUND

Cerebrospinal fluid (CSF) leaks in the temporal bone arise from osteodural defects, resulting in an abnormal connection between the subarachnoid space and the adjacent tympanomastoid cavity, which often manifests as otorrhea. Patients typically exhibit symptoms such as headache, unilateral hearing impairment, aural fullness, or even meningitis. Imaging studies are critical for identifying and differentiating the location and characteristics of CSF leaks. However, when the leak's origin remains ambiguous, diagnostic surgery may be warranted to both confirm the diagnosis and facilitate treatment. This report discusses an uncommon case while reviewing relevant literature, focusing on the surgical diagnostic intervention in a 58-year-old male with spontaneous temporal bone CSF leaks.

CASE SUMMARY

The patient, a 58-year-old man, was admitted for evaluation of left ear fullness, hearing loss, and nasal discharge. Notably, when supine, clear fluid drained from the left nasal cavity, with improvement noted upon sitting. A nasal examination did not reveal significant findings, while the otologic evaluation indicated an intact periosteum; however, considerable fluid accumulation was identified within the left middle ear. Despite undergoing multiple periosteal punctures and conservative medical management, the middle ear effusion persisted. Imaging studies, including magnetic resonance imaging (MRI) and computed tomography, confirmed the presence of left-sided CSF otorrhea, and the head MRI indicated potential CSF rhinorrhea. This raised challenges in determining whether the CSF leak originated from the sphenoid sinus or the temporal bone. Given that CSF otorrhea may drain through the external auditory canal and CSF rhinorrhea from the sellar region can present as nasal leakage, differentiation proved complex. In this case, with an intact external auditory canal, CSF from the middle ear was observed to flow into the nasal cavity via the Eustachian tube. Therefore, leakage from both sites could be misconstrued as CSF rhinorrhea, complicating the diagnostic process. Consequently, an exploratory surgical procedure was performed, revealing an incomplete dura mater on the temporal aspect of the petrous bone, which was subsequently repaired.

CONCLUSION

Benign intracranial hypertension can result in meningeal protrusion or meningoencephalocele, which may lead to CSF leakage that generally responds favorably to mucosal repair. In instances where imaging fails to identify the source of the leak or when diagnostic options are limited, proactive exploratory surgery is advisable. Although surgical interventions carry inherent risks, the application of endoscopic techniques by experienced surgeons renders this approach a feasible choice for addressing both diagnostic and therapeutic challenges.

Safety, Sequelae, and Efficacy of Nerve Root Clipping in Patients With Spontaneous Spinal Cerebrospinal Fluid Leaks

BACKGROUND AND OBJECTIVES

Spinal cerebrospinal fluid (CSF) leaks may cause a myriad of clinical symptoms, the most common being orthostatic headache. Lateral leaks (Type II) and direct CSF-venous fistulas (Type III) are a subgroup of spinal CSF leaks, representing about 1/3 of spinal CSF leaks. This study aimed to analyze the risk and efficacy of nerve root clipping in patients with Type II and Type III CSF leaks.

METHODS

All consecutive patients with Type II and Type III CSF fistulas treated with nerve root clipping at our institution from May 2018 to December 2022 were included. Patients were evaluated for postoperative sensory motor deficits and neuropathic pain using the "Douleur Neuropathique 4" questionnaire, and the outcome was evaluated using the "Patient Global Impression of Change" and the return-to-work rate.

RESULTS

A total of 40 patients were included, and the mean follow-up time was 22 months. According to the Patient Global Impression of Change, significant symptoms improvement was reported in 85% of patients. Over 87% of patients returned to work fully or partially. One patient experienced a low-grade motor deficit after T1-nerve root clipping. 2.5% of patients developed postoperative neuropathic pain requiring medical treatment under which they fully improved. Over 80% of patients developed dermatomal hypoesthesia, with no reported effect on quality of life.

CONCLUSION

The surgical strategy of noneloquent nerve root clipping shows favorable outcomes and return-to-work rates. There are instances of neuropathic pain and dermatomal hypoesthesia with no significant morbidity. Despite the favorable outcome and low recurrence rate, nerve root-sparing surgical techniques should be further explored.

Lower spinal levels and male sex are associated with greater epidural blood patch volume in spontaneous intracranial hypotension

BACKGROUND

The epidural blood patch (EBP) is the treatment of choice for spontaneous intracranial hypotension (SIH). Studies have shown that targeted EBP is more effective than blind EBP. Additionally, a greater volume of injected blood during EBP has been associated with better therapeutic outcomes. However, symptoms such as back pain often prevent achieving the desired blood volume. This study aimed to analyse factors influencing the tolerable EBP volume, including structural, clinical, and psychological factors.

METHODS

This retrospective study included patients diagnosed with SIH who underwent single-level EBP at a tertiary care centre from 2019 to 2024. Data collected encompassed target levels, cross-sectional area, types of EBP, demographics, imaging findings, maximum intensity of orthostatic headache, Headache Impact Test-6, psychological state (Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9), and somatic symptom burden (Widespread Pain Index and Symptom Severity Scale). A linear mixed model (LMM) was used to investigate factors influencing the total injected blood volume, accounting for repeated EBP procedures per patient. Sensitivity analysis was performed to assess model robustness.

RESULTS

A total of 103 EBP procedures from 53 patients (62% female; mean age, 39.9 ± 11.1 years) were analysed. The results of the LMM revealed that lower spinal levels (beta = 0.306, P = 0.029) and male sex (beta = 4.347, P = 0.024) were significantly associated with higher tolerable EBP volumes. Psychological factors or somatic symptom burden did not have a significant impact on the injected blood volume. In the sensitivity analysis, the number of EBP procedures (beta = -0.804, P = 0.001) was also significantly associated with lower tolerable EBP volume.

CONCLUSIONS

Lower spinal levels and male sex were associated with higher tolerable EBP volumes in patients with SIH. The trade-off between spinal level and tolerable EBP volume should be considered when developing targeted blood patch strategies and evaluating their efficacy.

Assessing the Diagnostic Value of Brain White Matter Hyperintensities and Clinical Symptoms in Predicting the Detection of CSF-Venous Fistula in Patients with Suspected Spontaneous Intracranial Hypotension

BACKGROUND AND PURPOSE

Spontaneous intracranial hypotension (SIH) due to CSF-venous fistula (CVF) is increasingly recognized as a secondary cause of headaches, with symptoms often overlapping with primary headache syndromes such as migraine. While brain MRI studies have focused on features indicative of SIH, findings that support an alternate headache etiology, such as the bifrontal white matter hyperintensities (WMH) often seen in migraines, have not been explored in this context. This study assesses the following: 1) the quantity and distribution of WMH, and 2) the presenting clinical features in patients with and without CVF found on dynamic decubitus CT myelography (dCTM).

MATERIALS AND METHODS

Seventy-two consecutive patients underwent clinical work-up for SIH due to suspected CVF, including preprocedural brain and spine MRI followed by dCTM. Brain imaging features were analyzed, including the Bern score, quantitative WMH burden, and WMH distribution. Demographics and clinical symptoms present at the time of presentation were recorded. Imaging features were compared between groups with and without CVF using parametric or nonparametric comparisons according to variable normality. Multivariate logistic regression explored the relationships among imaging features, clinical symptoms, and the presence of CVF.

RESULTS

The cohort included 40 patients with (CVF+) and 32 patients without (CVF-) CVFs, with no significant age or sex differences. Patients with CVF+ had significantly higher Bern scores and significantly fewer WMH. There were significant differences in the frequencies of WMH patterns between groups, with a migrainous pattern observed most frequently in patients with CVF-. Logistic regression combining the Bern score, WMH burden, and WMH pattern demonstrated a better fit for predicting CVF than using the Bern score or WMH features alone. Fourteen clinical symptoms showed the greatest differences between CVF+ and CVF- groups. Logistic regression demonstrated a positive association between CVF detection and a pressure/throbbing headache quality and negative associations for neck pain, facial pain, phonophobia, and anhedonia/depression.

CONCLUSIONS

These findings suggest a negative association between CVF detection, increased burden of WMH, and a migrainous WMH pattern. Symptom analysis describes distinct clinical phenotypes, challenging orthostatic headache as a defining characteristic. These results support a comprehensive assessment of imaging and clinical presentations in the work-up of suspected SIH.

No evidence of intracranial hypotension in persistent post-traumatic headache: A magnetic resonance imaging study

BackgroundPersistent post-traumatic headache (PTH) is frequent, and intracranial hypotension may be an important cause of PTH. The present study aimed to examine whether magnetic resonance imaging (MRI) signs of intracranial hypotension are more frequent in people with persistent PTH than in healthy controls (HCs).MethodsAdults with persistent PTH attributed to mild traumatic brain injury and age- and sex-matched HCs attended a single non-contrast, brain MRI 3T session. Fluid attenuated inversion recovery T1- and T2-weighted sequences were acquired to assign a modified Bern score. The score ranges from 0 to 9 points, with higher scores indicating a greater probability of cerebrospinal fluid (CSF) leakage leading to intracranial hypotension. The primary outcome was the difference in modified Bern score between participants with persistent PTH and HCs. All images were examined by a certified neuroradiologist who was blinded to the group status.ResultsImaging data from 97 participants with persistent PTH and 96 age- and sex-matched HCs were eligible for analyses. A modified Bern score of ≤2 was present in 90 (93%) participants with persistent PTH and 85 (89%) HCs, indicating a low probability of CSF leak. None of the persistent PTH participants or the HCs had a score of >4. There were no significant differences in modified Bern scores between participants with persistent PTH and HCs.ConclusionsThere is a low prevalence of typical MRI Bern score signs of intracranial hypotension in PTH or HCs. Thus, intracranial hypotension is unlikely to be an underlying factor in persistent PTH attributed to mild traumatic brain injury.Trial RegistrationThe study was registered on ClinicalTrials.gov (identifier: NCT03791515). Date of registration 2018-12-29.

A case of progressive and irreversible visual loss as a consequence of delayed diagnosis in cerebrospinal fluid venous fistula

PurposeCerebrospinal fluid venous fistulas (CVFs) are a frequently underrecognized cause of cerebrospinal fluid (CSF) leaks, leading to intracranial hypotension and a wide range of symptoms, including visual disturbances. This case highlights the critical role of ophthalmologists in identifying CVFs as a cause of unexplained progressive vision loss.MethodsWe present the case of a 45-year-old woman who developed progressive visual field loss over 15 years, ultimately resulting in blindness in one eye. Early neuroimaging and testing were normal despite symptoms of orthostatic headaches, photophobia, and hearing loss. Advanced imaging eventually identified a CVF at the T8 level. Surgical correction was performed, and the patient's clinical response was assessed.ResultsSurgical repair of the CVF led to clinical improvement, halting further progression of symptoms.ConclusionsCVFs should be considered in patients with unexplained visual disturbances, particularly when accompanied by symptoms of intracranial hypotension. Early suspicion and collaboration with neurologists and neuroradiologists are essential for timely diagnosis and intervention. Ophthalmologists play a pivotal role in guiding appropriate referrals, ensuring multidisciplinary care to prevent irreversible visual and systemic complications.

Assessing the effects of spontaneous intracranial hypotension on quality of life, work ability and disability

BACKGROUND

Spontaneous intracranial hypotension (SIH), characterized by headaches due to cerebrospinal fluid leaks or low pressure, is a challenging condition to diagnose and treat and affects the quality of life.

METHODS

An 8‑week online survey was conducted to assess the impact of SIH on symptoms, sociodemographics and quality of life. The cohort was comprised of patients who had a self-reported diagnosis of SIH and were divided into two groups: those with radiological evidence of SIH and those with clinical suspicion but no radiological evidence. Mental health and disability were evaluated using the Depression, Anxiety and Stress Scale-21 (DASS-21) and the Henry Ford Hospital Headache Disability Inventory (HDI).

RESULTS

A total of 86 participants were included in the study, 59 with radiological evidence and 27 without. Most participants were female (84.9%) with a mean age of 44.8 years. Orthostatic headache was more common in participants without radiological evidence (74.1% vs. 42.4%). The severity in those with radiological evidence was 27.1% mild, 27.1% moderate, 30.5% severe and 15.3% extremely severe, while those without had 7.4% mild, 18.5% moderate, 63.0% severe and 11.1% extremely severe headaches. Mental health assessment using the DASS-21 scale showed that 77.9% of all participants reported signs of depression, 96.5% reported anxiety and 89.5% reported stress. The HDI showed 2.3% total disability, 40.7% severe, 19.8% moderate and 37.2% mild. The impact on employment was significant: 15.1% were able to work full-time, 48.8% part-time, 30.2% were unable to work and 5.8% retired early due to SIH.

CONCLUSION

The study demonstrates the broad impact of SIH affecting physical health, mental well-being, and socioeconomic status, and calls for multifaceted and robust management approaches to address its complex effects on patients.

Intracranial pressure monitoring in patients with spontaneous onset of orthostatic headache

BACKGROUND

Spontaneous intracranial hypotension (SIH) is a debilitating disorder, with an estimated annual incidence of 3.7 per 100,000. Diagnosing SIH can be challenging for clinicians, as patients frequently present with normal investigation findings. Intracranial pressure (ICP) monitoring has been proposed as a valuable tool for patients with orthostatic headaches that are highly suggestive of SIH but have inconclusive investigation results. The primary objective of this study was to determine the proportion of patients with spontaneous orthostatic headaches and normal diagnostic work-up who exhibited abnormal ICP monitoring results.

METHODS

This single-centre, retrospective observational study was conducted at a tertiary referral centre specialising in SIH and CSF dynamics disorders. Consecutive patients with spontaneous orthostatic headaches and inconclusive diagnostic work-up who underwent 24-hour ICP monitoring were considered eligible. The 24-hour ICP monitoring followed a standardised protocol, measuring median ICP and pulse amplitude (a marker of brain compliance) during the daytime, nighttime, and over the entire 24-hour period. Specific cut-offs for low and high ICP states were predetermined based on the best available current evidence.

RESULTS

Thirty-eight patients (23 females, mean age 41 years ± 14SD) were identified. All patients had orthostatic headaches with a spontaneous onset. The mean duration of symptoms was 46 months ± 36SD. ICP monitoring identified 3 patients (7.9%) with low ICP (mean of the median 24-hour ICP - 2 mmHg ± 2SD) and 6 patients (15.8%) with high ICP (mean of the median 24-hour ICP 9 mmHg ± 3SD). Obvious CSF dynamics disturbances were excluded in the remaining 29 patients (76.3%, mean of the median 24-hour ICP 3 mmHg ± 3SD). The only clinical feature that was more common in patients with abnormal ICP compared to patients with normal ICP results was audiovestibular disturbance, namely aural fullness or muffled hearing (67% versus 17%, p = 0.015). There were no complications from the ICP monitoring procedure for any patient.

CONCLUSIONS

When appropriately selected, patients with a clinical picture highly suggestive of SIH, who have a negative diagnostic work-up, may benefit from consideration of invasive ICP monitoring. Moreover, a significant minority of patients with orthostatic headache may paradoxically have a high CSF pressure state, which can be detected using ICP monitoring.

MEETING PRESENTATIONS

Portions of this work were presented in abstract and oral presentation form at the Twenty-eighth Anglo-Dutch Migraine Association meeting (08/06/2018), the Tenth Meeting of the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders (20/10/2018; Bologna, Italy), the Society of British Neurological Surgeons 2018 Autumn Meeting (19/09/2018; London, United Kingdom), and the European Association of Neurosurgical Societies 2023 congress (27/09/2023; Barcelona, Spain). This work is also part of the doctoral thesis of one of the authors (LD).

β-Trace Protein as a Potential Biomarker for CSF-Venous Fistulas

BACKGROUND AND PURPOSE

Accurately identifying patients with CSF-venous fistulas (CVF) causing spontaneous intracranial hypotension, is a diagnostic dilemma. This conundrum underscores the need for a CVF biomarker to help select who should undergo an invasive myelogram for further diagnostic work-up. β-trace protein (BTP) is the most abundant CNS-derived protein in the CSF and, therefore, is a potential venous biomarker for CVF detection. The purpose of our study was to measure venous BTP levels as a potential CVF biomarker.

MATERIALS AND METHODS

We prospectively enrolled 14 patients with CVFs and measured the BTP in venous blood samples from the paraspinal veins near the CVF and compared those levels with those in the peripheral blood. Myelograms used initially to identify the CVF were evaluated for technique, CVF laterality, CVF level, and the venous drainage pattern. Patient sex and age and symptom duration were also collected. Brain MR images were reviewed for Bern scores. We also measured the peripheral blood BTP levels in 20 healthy controls.

RESULTS

In patients with CVF, the mean BTP level near the CVF was 54.5% higher (0.760 [SD, 0.673] mg/L versus 0.492 [SD, 0.095] mg/L; P = .069) compared with peripheral blood. Nine (64.3%) patients with CVFs had a higher paraspinal BTP level than peripheral BTP level. The 20 control patients had a higher mean peripheral BTP level of 0.720 (SD, 0.191) mg/L compared with patients with CVF (P < .001).

CONCLUSIONS

We found that venous blood at the site of the CVF had higher BTP values compared with peripheral blood in most but not all patients with CVF. This finding may reflect the intermittent leaking nature of CVF. Additionally, we found that patients with CVF had a lower peripheral blood BTP level compared with healthy controls. BTP requires further evaluation as a potential CVF biomarker.

Causes of Intracranial Hypotension: Spontaneous, Traumatic, and Iatrogenic Cerebrospinal Fluid Leaks

Cerebrospinal fluid leaks are important to recognize because they can cause debilitating symptoms for patients and have life-threatening complications. Leakage of cerebrospinal fluid (CSF) from the subarachnoid space can occur at the cranial or spinal level, with distinct clinical presentations, diagnostic evaluations, and treatment modalities depending on the type and location of the leak. Spontaneous, traumatic, and iatrogenic spinal CSF leaks cause reduced intracranial CSF volume and the clinicoradiologic syndrome commonly called "intracranial hypotension". This review discusses the clinical presentations, etiologies, and risk factors of spinal and cranial CSF leaks.

Effect on the size of optic nerve sheath diameter in patients undergoing surgeries under spinal anaesthesia versus peripheral nerve blocks - A randomised controlled study

Background and Aims

Post-dural puncture headache is a complication of spinal anaesthesia, theorised to be triggered by a lowering in intracranial pressure due to the cerebrospinal fluid leak through the dural puncture. Our objective was to evaluate whether there is a decrease in optic nerve sheath diameter (ONSD) with a reduction in intracranial pressure after spinal anaesthesia.

Methods

Patients were randomised by a computer-generated randomisation table to receive spinal anaesthesia (Group S) or peripheral nerve block (Group P) after assessing their eligibility for the anaesthesia procedure as per the protocol. The ONSD was measured in the preoperative period and again at 4 h and 24 h after the anaesthetic, both in the supine and sitting positions, along with haemodynamic parameters. Continuous variables such as age, height, weight, mean arterial pressures, and ONSD were expressed as mean [standard deviation (SD)] [95% confidence interval (CI)] and compared using the student's t-test. Repeated measure ANOVA and Bonferroni were used to compare intra-group parameters.

Results

The mean decrease in the ONSD from a baseline mean of 3.95 (SD: 0.17) (95%CI: 3.87, 4.02) to 3.89 (SD: 0.26) (95%CI: 3.78, 4.007) mm at 4 h and 3.94 (SD: 0.12) (95%CI: 3.89, 4.0) mm at 24 h after spinal anaesthesia was statistically significant. The changes in the ONSD measurements in Group P were not statistically significant. Headache was not reported at 24 h or in the follow-up at postoperative day 5.

Conclusion

Measurement of ONSD is an easy, economical method for identifying decreased intracranial pressure after spinal anaesthesia. Further research could identify cut-off values to prognosticate PDPH in high-risk individuals.

Brainstem changes causing reversible RBD in patients with spontaneous intracranial hypotension: a longitudinal neuroimaging study

OBJECTIVE

This study aimed to investigate the prevalence of REM sleep behavior disorder (RBD) in patients with spontaneous intracranial hypotension (SIH) and longitudinally assess the effects of epidural blood patch (EBP) treatment on brainstem structures using a neuroimaging approach.

METHODS

Twenty-two participants (10 SIH patients and 12 controls) underwent 3-Tesla Magnetic Resonance Imaging (MRI) scans. Midbrain and pons areas were measured on T1-weighted scans at baseline in both groups and three months after the first EBP in SIH patients to determine any MRI structural changes. The RBD Single-Questionnaire was used to screen SIH patients with symptoms suggestive of RBD for polysomnographic (PSG) recording.

RESULTS

Half of the SIH patients (5/10) exhibited PSG-confirmed RBD. Baseline evaluation revealed deep brain swelling (DBS) on MRI scans in SIH-RBD patients. Following EBP treatment, significant changes in midbrain and pons morphometry were associated with complete clinical remission of RBD. Cross-sectional analysis showed larger midbrain and pons areas in SIH patients (with and without RBD) compared to controls. A midbrain area of 200 mm2 was identified as a cut-off value distinguishing SIH patients (with and without RBD) from controls individually. Longitudinal analysis demonstrated lower midbrain areas at follow-up compared to baseline in SIH patients.

DISCUSSION

The study suggests that brainstem morphometric changes may underlie reversible RBD in SIH patients. Midbrain area measurement could serve as a dynamic biomarker for SIH, particularly in the presence of RBD, offering insights for clinical practice.

SIH-EBP score for prediction of efficacy of epidural blood patching in patients with spontaneous intracranial hypotension

BACKGROUND

Epidural blood patching (EBP) is the primary treatment for spontaneous intracranial hypotension (SIH), although multiple attempts may sometimes be necessary. The SIH-EBP score, with a cutoff of ≥3, predicts the response to the first EBP. However, its generalizability requires further confirmation. This study aims to validate the clinical utility of the SIH-EBP score and determine the optimal cutoff for predicting the response to the first EBP in an independent cohort of patients with SIH.

METHODS

This retrospective study included patients with SIH who received at least one EBP at a tertiary medical center. Clinical data were extracted from electronic medical records, and brain and spinal magnetic resonance images were reviewed.

RESULTS

Ninety-six patients (58 female [F]/38 male [M], mean age: 42.67 ± 10.16 years) were screened, with 49 (32 F/17 M, mean age: 41.20 ± 9.13 years) analyzed, including 30 (22 F/8 M, mean age: 41.10 ± 10.14 years) (61.2%) responders. There was a positive correlation between SIH-EBP scores and responder rates ( p = 0.001). A cutoff score of ≥3 was associated with a higher response rate than a score of <3 (80.0% vs 41.7%, p = 0.006) (sensitivity = 73.7%, specificity = 66.7%, accuracy = 69.4%). The optimal cutoff in this cohort was ≥2 (Area under curve (AUC) = 0.77, p < 0.001) (sensitivity = 52.6%, specificity = 90.0%, accuracy = 75.5%).

CONCLUSION

In this cohort, the SIH-EBP score correlated with response rates to the first EBP. Although a score of ≥3 remains a valid predictor of treatment response, a cutoff of ≥2 proved to be more accurate and specific. However, its practical use is limited by a sensitivity of 52.6%. Further studies are needed to verify its role in other populations.

Role of CT myelography in the diagnosis and management of spontaneous intracranial hypotension

INTRODUCTION

Spontaneous intracranial hypotension (SIH) is a secondary cause of headache. Its pathophysiology is complex, and relies mainly on the notion of a localized leak, and thus a loss of cerebrospinal fluid (CSF) in the spinal region. SIH is little known to the medical profession, for which CT myelography is a technique on the rise, allowing to identify and treat the leak using a blood-patch or a fibrin sealant. The aim of the study was to investigate the contribution of CT myelography in the diagnostic and therapeutic management of spontaneous intracranial hypotension, its modalities and population characteristics.

MATERIAL AND METHODS

A cohort of patients with spontaneous intracranial hypotension who underwent a CT myelography in our department was retrospectively studied. Nineteen patients were included between March 2020 and October 2022.

RESULTS

CT myelography allowed identification of an etiology in 16 patients (84 %). The etiology of the leak was mainly a dural tear, identified in 11 patients. One diverticulum and 4 CSF-venous fistulas were identified. First targeted injection of fibrin sealant allowed stopped the leak in 12 out of 17 patients.

CONCLUSION

CT myelography allows to identify the etiology of the CSF leak and pinpoint its topography. CT guidance can then be used to treat the leak in the same therapeutic timeframe, with greater efficacy during the first targeted injection of fibrin sealant. The current study data showed a high incidence of dural tears, and a significant proportion of venous-dural fistulas, and a low incidence of diverticulum.

Long-Term Headache Outcome and Radiological Correlates in Patients With Intracranial Hypotension

BACKGROUND

Headache is the most common presenting symptom of intracranial hypotension (IH), and it usually has orthostatic features. However, the outcome of IH and the persistence and characteristics of headache are still overlooked.

METHODS

In this cohort study, patients diagnosed with IH in our institute between 2018 and 2024 were included. Demographical and clinical data, headache characteristics, etiology, type of treatment (epidural blood patch (EBP), surgical or conservative), and MRI findings were collected. We conducted follow-up visits on headache characteristics and the persistence of headache ≥ 12 months of EBP/conservative treatment.

RESULTS

Forty-five patients with a diagnosis of IH were included (mean age of 53.0 ± 14.9 years); 35 (77.8%) were diagnosed with spontaneous intracranial hypotension (SIH) and 10 (22.2%) with secondary IH. EBP was performed on 22 patients (48.9%). Headache was the most common symptom at presentation, in 38/45 patients (84.4%), with orthostatic features in 32 (71.1%). Forty-four patients (97.8%) had brain MRI abnormalities. Follow-up visits were conducted after 31.6 ± 15.7 months; 28/41 (68.3%) patients reported headache during the first 12 months, and 22/41 (53.7%) ≥ 12 months. Headache persistence for ≥ 12 months was significantly lower in patients who received EBP (27.3%) compared to those who did not (63.2%) (p = 0.021). Logistic regression showed that receiving EBP was the only factor significantly associated with reduced likelihood of persistent headache for ≥ 12 months (OR = 0.082, 95% CI [0.007,0.903], p = 0.041). Radiological features differed significantly between patients with SIH and those with secondary etiologies.

CONCLUSION

A large proportion of patients with IH continue to experience headache beyond one year; EBP was the only predictor of headache persisting ≥ 12 months.

Outcome and Predisposing Factors for Intracranial Hemorrhage in Turkish Children with Hemophilia

Background/Objectives: Childhood hemophilia, a hereditary bleeding disorder predominantly affecting males, arises due to gene mutations encoding clotting factors VIII or IX. Intracranial hemorrhage represents a significant and life-threatening complication in pediatric patients with hemophilia. The incidence of intracranial hemorrhage in children with hemophilia, although relatively low, is notably higher compared to the general pediatric population. Methods: In this study, the objective is to examine patients with hemophilia who have experienced intracranial hemorrhage retrospectively. This study is a multicenter, retrospective analysis using data from three tertiary care centers in a provincial city in Turkey. Data were obtained from the participants' hospital records. The presence of inhibitors against FVIII in the participants and the prophylaxis used against them were included in the analysis. Trauma history was queried, with types of traumas examined, including traffic accidents, falls, and a traumatic vaginal delivery. The duration and causes of complaints among the participants were investigated. The causes of complaints were categorized as fever, hematoma, convulsions, loss of consciousness, and hemiparesis. The participants' Physical Examination Findings were classified as fever, hematoma, and loss of consciousness. The duration of hospital stays was evaluated. The hemorrhage location was classified into five groups: parenchymal, subdural, scalp, subarachnoid, and multiple hemorrhagic foci. The recurrence of bleeding, the need for transfusion, surgical intervention, and mortality were also examined. Results: A significant difference was identified between the participants' survival rates and age variables, as well as transfusion in <36 months. A total of 9 participants had spontaneous intracranial bleeding, 2 experienced cranial trauma as a result of traffic accidents, and 25 participants were exposed to head trauma due to falls. Of the remaining individuals, one suffered head trauma from a severe impact, and one had cranial trauma following a traumatic vaginal delivery. Fourteen participants required transfusion, and three underwent surgical intervention. Conclusions: According to the results of the statistical analyses, the variables Factor Level, Physical Examination Findings, Transfusion, Recurrent Bleeding, Inhibitor, and Prophylaxis were found to affect survival significantly. No significant relationship was determined between the other analyzed variables and survival. During our study, five of the participants examined died. Accordingly, the mortality rate identified in our study is 13.1%.

CT-Guided Epidural Contrast Injection for the Identification of Dural Defects

Post-dural puncture headache is an increasingly recognized cause of chronic headache. Outside of clinical history and myelography that requires an additional dural puncture, there is no reliable diagnostic test to evaluate for persistent dural defects. We describe the injection of iodinated contrast into the dorsal epidural space under CT guidance in 5 patients as a potential tool to visualize persistent dural defects.

Diagnosis and Management of Spontaneous Intracranial Hypotension Due to a CSF Leak: A Case of Spontaneous Recovery

Spontaneous intracranial hypotension (SIH) is a rare condition typically caused by a CSF leak at the level of the spine, leading to a reduction in intracranial pressure (ICP). This case describes a 55-year-old man who presented with visual disturbance, intermittent occipital headaches, nausea, altered hearing, and unsteady gait. The initial MRI of the head showed shallow bilateral subdural hematomas, which were believed to be secondary to the stretching of subdural veins. A diagnosis of probable intracranial hypotension was made and further radiological imaging of the spine was carried out to look for the presence of a CSF leak. A CT myelogram identified a CSF leak in the anterior part of the dura at the T1/T2 level, which was believed to be secondary to a bony spur. There are no well-defined statistics on the incidence of the causes of SIH. After a multidisciplinary discussion, a targeted CT-guided epidural blood patch was planned; however, the patient reported improvement in symptoms, so the procedure was abandoned, with serial follow-ups advised.

Spontaneous intracranial hypotension - a spinal disease

Spontaneous intracranial hypotension (SIH) remains an underdiagnosed condition despite increasing awareness due to recent scientific advances. Diagnosis can be delayed by the broad clinical presentation and imaging pitfalls. This results in a high degree of physical impairment for patients, including social and psychological sequelae as well as long-term damage in the case of delayed diagnosis and treatment.The study is based on a selective literature search on PubMed including articles from 1990 to 2023 and the authors' clinical experience from working in a CSF center.SIH mostly affects middle-aged women, with the primary symptom being position-dependent orthostatic headache. In addition, there is a broad spectrum of possible symptoms that can overlap with other clinical conditions and therefore complicate the diagnosis. The causative spinal CSF loss can be divided into three main types: ventral (type 1) or lateral (type 2) dural leak and CSF-venous fistula (type 3). The diagnosis can be made using a two-stage workup. As a first step, noninvasive MRI of the head and spine provides indicators of the presence of SIH. The second step using focused myelography can identify the exact location of the cerebrospinal fluid leak and enable targeted therapy (surgical or interventional). Intrathecal pressure measurement or intrathecal injection of gadolinium is no longer necessary for primary diagnosis. Serious complications in the course of the disease can include space-occupying subdural hematomas, superficial siderosis, and symptoms of brain sagging, which can lead to misinterpretations. Treatment consists of closing the dural leak or the cerebrospinal fluid fistula. Despite successful treatment, a relapse can occur, which highlights the importance of follow-up MRI examinations and emphasizes the chronic nature of the disease. This paper provides an overview of the diagnostic workup of patients with suspected SIH and new developments in imaging and therapy. · SIH is an underdiagnosed condition with a wide range of possible symptoms.. · The first diagnostic step using MRI provides indications of the presence of SIH.. · The second diagnostic step using (dynamic) myelography can identify the CSF leak.. · Collaboration with a CSF center is advisable for further diagnosis and treatment.. · Prompt detection and treatment of SIH improves the outcome.. · Zander C, Wolf K, El Rahal A et al. Spontaneous intracranial hypotension - a spinal disease. Fortschr Röntgenstr 2024; DOI 10.1055/a-2318-8994.

Spontaneous intracranial hypotension - Neurological symptoms, diagnosis, and outcome

BACKGROUND

Spontaneous intracranial hypotension (SIH) is a rare secondary headache disorder caused by spinal leakage of cerebrospinal fluid. Specialized treatment of SIH consists of epidural blood patches (EBPs), fibrin patching, endovascular sealing, and surgery. The aim of this paper was to characterize SIH patients identified at a tertiary headache center.

METHODS

Eighty patients with SIH identified at the Danish Headache Center were included in this clinical cohort study. Data on demographics, clinical presentation, imaging findings, effect of EBPs, and invasive procedures were collected in a standardized manner. Prognostic elements of EBP treatment outcome were evaluated statistically with success defined as a minimum 30% intensity reduction sustained for at least 1 month.

RESULTS

The average age was 47 years and 53% were female. Peracute and subacute onset was noted in 35% and 36%, respectively. Orthostatic headache was noted in 85% of cases. The median Bern score was 4, and of identified leaks, 52% were type 1, 22% type 2, 22% type 3, and 4% type 4 (defined as peripheral leakage distally for the root pouch). Successful treatment response was 34% for EBPs and 90% for invasive procedures. Prepontine cistern effacement was more prevalent in patients with successful first EBP than without (p = 0.013).

CONCLUSION

SIH patients presented with a wide variety of symptoms with high prevalence of orthostatic headache. Peracute onset was noted in 35% and calls for more awareness in the acute setting. We found prepontine cistern effacement to be a potential predictor of a successful first epidural blood patch.

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

Cerebrospinal Fluid Leaks: Diagnosis, Management, and Outcomes

Cerebrospinal fluid (CSF) leaks are a challenging condition characterized by the loss of CSF, leading to severe orthostatic headaches and other debilitating symptoms. Diagnosis and management require a multifaceted approach involving clinical evaluation, imaging, and various treatment modalities to improve patient outcomes and quality of life.

Defining the typical characteristics of orthostatic headache in patients with spontaneous intracranial hypotension

BACKGROUND

Orthostatic headache (OH) is a common feature of various conditions, including spontaneous intracranial hypotension (SIH), but no precise definition currently exists outlining the typical OH characteristics. This ambiguity risks misdiagnosis with unnecessary investigations and delay in institution of treatment. The present study aimed to carry out structured phenotyping of OH in patients with SIH with the aim of outlining its typical characteristics.

METHODS

Eligible patients with clinico-radiological confirmed SIH underwent a structured interview, after which a specialist interest group utilised the modified Delphi process to analyse the data and achieve consensus on defining the typical characteristics of OH in SIH.

RESULTS

In total, 137 patients were recruited. OH was present in 75.9%. Typical OH characteristics in SIH were defined as having a baseline severity (lying flat) on waking up of ≤3 (0-10, verbal response scale), headache onset-time of ≤4.5 h on becoming upright, time to peak severity of ≤7.5 h and an offset to baseline severity within 1.5 h of recumbency. Intra-individual consistency in the onset and offset-time was deemed a necessary characteristic.

CONCLUSIONS

Defining typical OH characteristics has the potential of enhancing SIH diagnostics and management, at the same time as minimising unwarranted invasive procedures.

Evidence-based approaches to cranial cerebrospinal fluid leaks in low- and middle-income countries: a systematic review of the literature

Cerebrospinal fluid (CSF) leaks commonly occur due to trauma or surgical procedures. Here we review CSF leak diagnosis and management in Low- and Middle-Income Countries (LMICs). A systematic review of the CSF leak management in LMICs was conducted using PubMed, Google Scholar, Embase and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eighteen articles with 3,596 patients (mean age = 39.58 years) were analyzed. Of these patients, 31.37% (1,128/3,596) were reported to have developed cranial CSF leaks. The predominant presentation of CSF leak included symptoms of rhinorrhea, headache, meningitis, and visual impairment. The primary etiology of CSF leak was complications from endoscopic surgery (482 patients), followed by spontaneous origin (46 patients), craniotomy (44 cases), and trauma from motor vehicle accidents (43 cases). Computed tomography (CT) scans (10 retrospective, 15 case, and 1 comparative study) and magnetic resonance imaging (MRI) (6 retrospective, 11 case, and 2 comparative studies) were identified as the most utilized diagnostic modalities. The endoscopic endonasal technique emerged as the predominant surgical approach for managing CSF leak (5 retrospective, 13 case, and 1 comparative study). Moreover, both acellular dermal matrix and turbinate flaps demonstrated comparable repair rates in the management of CSF rhinorrhea (95.23% and 96.00%, respectively). Additionally, porcine-derived fibrin sealant exhibited enhanced success rates for repairs in craniotomies, increasing from 49.21% to 97.81%. This study demonstrates progress in the diagnosis, treatment, and management of cerebrospinal fluid (CSF) leaks within LMICs, including the noteworthy advancement from traditional microscope utilization to the endoscopic endonasal technique.

Incidental asymptomatic spinal cerebrospinal fluid leaks: single-center experience, and a presentation of seven cases

BACKGROUND

The majority of patients with spontaneous intracranial hypotension (SIH) are symptomatic. Some patients are discovered incidentally. The proportion of asymptomatic SIH has never been defined. This article reports our institution's rate of asymptomatic cases among all of our patients with high/intermediate Bern scores on brain MRI, etiology of leak in asymptomatic cases, complications of asymptomatic leaks, and evolution of imaging before and after treatment.

METHODS

We retrospectively analyzed data from the Cerebrospinal Fluid (CSF) Dynamics clinic spanning September 2020 to July 2023. Bern score was calculated from all available brain MRIs in patients with confirmed leaks. Patients with iatrogenic leaks or no brain MRI were excluded. The charts of asymptomatic patients were reviewed to obtain MRI indications, SIH progression, complications, leak type, and treatment outcomes.

RESULTS

Some 8.6% (7/81) patients with high/intermediate Bern scores were asymptomatic at the time of imaging. Two patients declined myelography. Four of seven asymptomatic patients were found to have CSF-venous fistulas and underwent embolization with radiographic improvement. Complications of asymptomatic leaks in this population included subdural hematoma and superficial siderosis.

CONCLUSIONS

Asymptomatic but clearly present spinal CSF leaks were not uncommon in our group. These results highlight the possibility of a presymptomatic phase in patients with CSF leaks. In our sample, myelography was readily positive for etiology of the leak, and leaks promptly responded to targeted treatment.

IIH, SIH and headache: Diagnosis and treatment update

Idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH) are two major secondary headache disorders resulting from abnormal intracranial pressure (ICP). This short communication outlines the pathophysiology, diagnostic criteria, and management strategies for IIH and SIH. IIH predominantly affects obese women of childbearing age and presents with daily headaches, visual disturbances, and papilledema. It is characterized by elevated cerebrospinal fluid (CSF) pressure, with diagnosis supported by imaging and lumbar puncture. Treatment includes weight reduction, medications, and surgical interventions in refractory cases. SIH, conversely, is caused by spontaneous spinal CSF leaks and presents with acute orthostatic headaches. Diagnosis is supported by neuroimaging and lumbar puncture, revealing low CSF pressure. Treatment includes supported care, (targeted) epidural blood patch, with surgical repair considered in refractory cases. Advances in imaging and treatment have significantly improved outcomes for both conditions.

Jugular venous narrowing and spontaneous spinal cerebrospinal fluid leaks: A case-control study exploring association and proposed mechanism

BACKGROUND

Spontaneous skull base cerebrospinal fluid leaks (CSFLs) are associated with increased intracranial pressure in idiopathic intracranial hypertension (IIH) and hypothesized to relate to skull base erosions due to increased CSF pressure. Given the increasing recognition of internal jugular venous stenosis (IJVS) as a cause of intracranial hypertension (IH), we evaluated the relationship between spinal CSFL and venous causes of IH.

METHODS

The spinal CSFL database at a single institution was assessed to identify 12 consecutive spontaneous, non-traumatic spinal CSFL patients with CTV data. Exclusion criteria included documented IIH and iatrogenic CSFL. Demographics, clinical parameters, imaging characteristics, and IJV manometry results were recorded. Internal jugular venous stenosis was graded as: none (0-10%), mild (10-50%), moderate (50-80%), severe (>80-99%), and occluded (100%). Twelve consecutive patients who presented with cerebrovascular accidents without CSFL, matched by age and sex, were similarly analyzed as a control group. STROBE guidelines were used in reporting results.

RESULTS

All CSFL patients had IJVS (83.3% bilateral, 33.3% severe) compared to 41.7% of the control group (33.3% bilateral, 16.7% severe-occluded); p = 0.04. All CSFL patients with available venogram manometry data had at least unilateral IJV gradients. Most patients presented with modified Rankin score (mRS) of 1 (66.7%), but in those with higher mRS, medical and/or surgical interventions were associated with decreased morbidity.

CONCLUSION

Spontaneous spinal CSFL was associated with IJVS in patients not meeting IIH criteria. Persistently high CSF pressure resulting in CSFL may cause opening pressure to be falsely normal or low. Internal jugular venous stenosis may be a viable target in recurrent CSFL management and improve morbidity.

Spontaneous Intracranial Hypotension and Dural Ectasia in Marfan Syndrome: An Illustrative Case Successfully Treated with Steroid Therapy and Literature Review

BACKGROUND

Spontaneous intracranial hypotension (SIH) is a rare and frequently misdiagnosed disorder characterized by a low volume of cerebrospinal fluid (CSF) caused by the leakage of CSF through the spinal dural membrane. Patients with Marfan Syndrome (MS) and other connective tissue disorders are at an increased risk for dural ectasia, which may predispose them to spontaneous CSF leaks due to the structural weakness of their dural membranes. The management of SIH in MS patients is debated. Conservative measures, an epidural blood patch (EBP), and surgical treatments are the options generally provided.

METHODS

Herein, we report on the case of a 52-year-old female affected by MS, genetically confirmed, with a two-month history of sudden-onset, "thunderclap" headache, worsened in an upright position and horizontal diplopia. A Computed Tomography (CT) scan of the brain showed a bilateral chronic subdural hematoma, slit ventricles, and a caudal descent of the brainstem without overt tonsillar herniation. The Magnetic Resonance Imaging (MRI) scan of the whole spine revealed dural ectasia in the lumbosacral area and presacral perineural cyst without extradural CSF collection. The case was successfully managed with bed rest and high-dose corticosteroid therapy. Then, we discuss the pertinent literature, consisting of 25 papers dealing with the treatment of SIH in patients affected by MS.

RESULTS

The literature review yielded 25 papers dealing with SIH management in patients with MS, including 28 patients overall; 21 patients underwent EBP, of whom 7 patients had multiple procedures. Overall, in 23 cases (82%), the symptoms improved. In three cases, the patients were managed conservatively with bed rest. In three of these cases, there was an improvement. In one case, the surgical fenestration of two lumbar intradural spinal meningeal cysts was performed and the patient improved after the procedure. Our patient underwent 15 days of steroid therapy (dexamethasone iv 12 mg/day for 7 days, then reduced to 4 mg/day) and intravenous hydration (Ringer lactate 1500 mL/day). In ten days, the symptoms disappeared. At the 6-month follow-up, the patient was in good clinical condition, and a CT scan showed an almost complete regression of the bilateral subdural hematoma.

CONCLUSIONS

The management of SIH in MS patients is still challenging. Patients with connective tissue disorders such as MS are at an increased risk for SIH. Few studies have assessed the management of these patients and different strategies. Our case and the available literature provide further data for this type of case.

The Challenges of Patients with Spinal CSF Leaks in Canada: A Cross-Sectional Online Survey

BACKGROUND

Spinal CSF leak can cause disabling headaches and neurological symptoms. Lack of awareness, diagnostic delay and treatment inconsistencies affect the quality of CSF leak care globally. This is the first study aiming to identify and assess these challenges in Canada.

METHODS

A cross-sectional online survey of Canadian patients with spinal CSF leak was designed in collaboration with Spinal CSF Leak Canada, including questions on demographics, headache condition, investigations, treatments, quality of life, financial consequences and out-of-country care.

RESULTS

The survey captured 103 respondents with confirmed spinal CSF leak diagnosis, of whom 56% were still suffering. The majority were female (80%), most being highly educated, with a mean age of 41.8 (SD: 10.37) years at the time of diagnosis. Inconsistencies in care resulted in variable durations for obtaining diagnosis and treatment. The majority of respondents (88%) had seen multiple physicians, and only 50% had seen a CSF leak specialist. Invasive imaging was not performed in 43%. CSF leak relapse after initial successful treatment occurred frequently (43%). The incidence of rebound intracranial hypertension was high (52.5%), and the treatment was difficult to access (77%). Out-of-country care was common (28%), and the impact on financial health was omnipresent (81.5%).

CONCLUSION

The survey demonstrates significant gaps in spinal CSF leak care in Canada, similar to global observations. Lack of awareness and access, delayed care, and inconsistencies in investigations and management are common. Spinal CSF leak significantly impacts patients' physical, mental and financial well-being. Increased awareness, referral pathways and standardized treatment algorithms are key factors in optimizing patient care in Canada.

Clinical Reasoning: A 32-Year-Old Man With Painless Bilateral Shoulder Girdle Weakness and Atrophy

We report a case of 32-year-old man with progressive, asymmetric, proximal weakness of both upper limbs for 14 months. On examination, he had gynecomastia and wasting and weakness of his deltoid, supraspinatus, infraspinatus, pectoralis, biceps, and triceps muscles, along with sensory loss of his left C5-C8 dermatomes. Deep tendon reflexes were depressed in the upper limbs and normal in the lower limbs. There was a history of a road traffic accident 2 years ago without any neurologic deficits. We discuss the clinical approach, differential diagnosis, investigations, and treatment options for bibrachial weakness.

Headache disorders in patients with Ehlers-Danlos syndromes and hypermobility spectrum disorders

Extra-articular symptoms, including headaches, are frequently encountered in patients with Ehlers-Danlos syndrome (EDS) and hypermobility spectrum disorders (HSD), and may be the presenting complaint. Migraine is reported in up to three quarters of patients with symptomatic joint hypermobility, have a higher headache frequency, and an earlier age of onset compared to the general population. Orthostatic headache is an important presentation, and should raise suspicion of an underlying spinal cerebrospinal fluid leak, dysautonomia, and craniocervical pathology, which are all associated with heritable connective tissue disorders (HCTD) including EDS. Any proposed invasive procedure should be scrupulously balanced against its potential risks, taking into account the type of EDS (e.g., vascular EDS) and its systemic manifestations. This is particularly pertinent when suspecting craniocervical instability since it remains a controversial diagnosis with a limited treatment evidence-base. This article reviews the commonly encountered headache disorders in patients with joint hypermobility-related conditions with a focus on EDS and HSD, describes their diverse presentations, and an overview of the recommended management strategies. It also emphasises the need for increased awareness of comorbid conditions in EDS and HSD among clinicians treating headaches to ensure a patient-tailored approach and facilitate a multidisciplinary approach in managing often complex cases.

ACR Appropriateness Criteria® Imaging of Suspected Intracranial Hypotension

The clinical syndrome of intracranial hypotension refers to the symptoms caused by cerebrospinal fluid hypovolemia and is primarily characterized by postural headaches, but can be associated with a multitude of other neurological symptoms. Imaging plays a critical role in helping to establish a diagnosis of intracranial hypotension, localize the source of cerebrospinal fluid leak, and assist in directing targeted treatments. Using the best available evidence, this document provides diagnostic imaging recommendations for the workup of intracranial hypotension across various clinical presentations. 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.

Sex differences in the clinical manifestations and treatment outcomes in a large cohort of spontaneous intracranial hypotension

OBJECTIVE

To determine sex differences in clinical profiles and treatment outcomes in patients with spontaneous intracranial hypotension.

BACKGROUND

Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether males and females should be managed differently.

METHODS

This was a cohort study of consecutive patients with spontaneous intracranial hypotension enrolled from a medical center. Medical records and imaging findings were reviewed. The outcome of treatment responses to epidural blood patches and risks of subdural hematoma were measured.

RESULTS

In total, 442 patients with spontaneous intracranial hypotension (165 males, 277 females) were included in the analysis. Males were more likely to have a delayed (>30 days) initial presentation than females (32.1% [53/165] vs. 19.9% [55/277], p = 0.004), and males were less likely to have nausea (55.8% [92/165] vs. 67.1% [186/277], p = 0.016), vomiting (43.0% [71/165] vs. 54.2% [150/277], p = 0.024), photophobia (9.7% [16/165] vs. 17.0% [47/277], p = 0.034), and tinnitus (26.7% [44/165] vs. 39.7% [110/277], p = 0.005) compared with females despite comparable radiologic findings. Among the 374 patients treated with epidural blood patches, males were more likely to be nonresponders to the first epidural blood patch (58.0% [80/138] vs. 39.0% [92/236], OR = 2.2, 95% CI = 1.4-3.3, p < 0.001). Males were at a higher risk of having subdural hematoma (29.7% [49/165] vs. 10.8% [30/277], OR = 3.5, 95% CI = 2.1-5.8, p < 0.001). Among patients with subdural hematoma, males had greater thickness (12.8 ± 4.3 vs. 8.1 ± 5.9 mm, p < 0.001) and were more likely to receive surgical drainage (55.1% [27/49] vs. 10.0% [3/30], OR = 11.0, 95% CI = 3.0-41.3, p < 0.001) than females.

CONCLUSION

In the present study, spontaneous intracranial hypotension in males was characterized by a delayed presentation, poorer response to the first epidural blood patch, and a higher risk of subdural hematoma. Caution should be exercised in the management of males with spontaneous intracranial hypotension. The generalizability of the findings needs to be further confirmed.

More than a headache-somatic and mental symptom burden in spontaneous intracranial hypotension before and after surgical treatment

Introduction

Patients with spontaneous intracranial hypotension (SIH) frequently present with several symptoms and impaired mental health. This study systematically investigates the somatic and mental symptom burden of SIH and the effect of surgical treatment.

Methods

In this single-center retrospective study, patients with surgical closure of a spinal cerebrospinal fluid leak between September 2022 and July 2023 completed the Somatic Symptom Scale (SSS-8), the Somatic Symptom Disorder - B Criteria Scale (SSD-12), and the Patient Health Questionnaire (PHQ-8) preoperatively and three and 6 months postoperatively.

Results

Fifty-seven patients were included. All three scores showed clearly pathological values before surgery (SSS-8: 12 [IQR 6.5-16], SSD-12: 26 [IQR 19.5-33.5], PHQ-8: 11 [IQR 6.5-15]) representing a high somatic symptom burden and relevant current depression. After surgery, there was a significant and sustainable improvement (SSS-8: 8 [IQR 3-11.75], SSD-12: 12.5 [IQR 5-21.75], PHQ-8: 4.5 [IQR 2-9], p < 0.001, respectively) that exceeded the minimal clinically important difference for every score.

Conclusion

SIH presents with high somatic and mental symptom burden. Surgical treatment leads to a relevant improvement of somatic and depressive symptoms. However, even after surgical success some patients still exhibit elevated depressive scores. Depressive symptoms might be added to the typical symptomatology of SIH.

Movement Disorders in Brain Sagging Syndrome Due To Spontaneous Intracranial Hypotension: A Review

Background

Spontaneous intracranial hypotension (SIH), a treatable condition that stems from spinal leakage of cerebrospinal fluid, usually presents with orthostatic headache, nausea, vomiting, dizziness, and tinnitus. A subset of patients, especially those with sagging of brain structures ("brain sagging syndrome"), develop several movement abnormalities. As SIH is treatable with epidural blood patch (EBP), movement disorders neurologists should be familiar with this syndrome.

Method

The authors performed a literature search in PubMed in July 2024 using the Boolean phrase- (("Brain sagging")OR("Intracranial hypotension"))AND(((((((((("Movement disorders")OR("Involuntary movements"))OR("Tremor"))OR("Dystonia"))OR("Chorea"))OR("Ballismus"))OR("Myorhythmia"))OR ("Tic"))OR("Ataxia"))OR("Parkinsonism")).

Result

We tabulated 21 case reports/series that highlighted the presence of movement disorders. The most reported phenomenology is gait unsteadiness. While it usually emerges in the background of the classic SIH symptoms, rarely, patients may present with isolated gait dysfunction. Tremor is the second most reported phenomenology with postural and kinetic tremor being the common subtypes. Holmes tremor has also been reported in SIH. Other reported phenomenologies are parkinsonism, chorea, and dystonia. One study reported a unique phenomenology i.e. compulsive repetitive flexion and breath holding in 35.3% of the patients. In majority of the patients, EBP resulted in substantial clinical and radiological improvement.

Discussion

Brain sagging syndrome due to SIH may present with a wide range of movement disorders. Mechanical distortion of the posterior fossa and subcortical structures result in the emergence of such movement abnormality. SIH adds to the list of conditions that result in "treatable movement disorders." Therefore, movement disorders neurologists should be versed with the diagnosis and clinical features of this condition.

Conventional clinical signs and symptoms are poor predictors of postoperative cerebrospinal fluid leak: A single-centre cohort perspective

BACKGROUND

Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks.

METHODS

Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression.

RESULTS

Seventy-nine patients (57.7%) had high-flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76-64.44]), throat drainage (3.42 [0.35-33.86]), salty/metallic taste (4.22 [0.66-27.04]), severe headache (3.00 [0.48-18.62]), dizziness (0.54 [0.06-4.94]), fever (3.16 [0.50-19.99]), and nausea/vomiting (1.33 [0.22-8.21]), associated with postoperative CSF leak.

CONCLUSIONS

A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response.

Diagnostic and therapeutic insights in individuals with persistent post-dural puncture headache: A cross-sectional study

BACKGROUND

Post-dural puncture headache (PDPH) is a frequent complication following lumbar puncture, epidural analgesia, or neuraxial anesthesia. The International Classification of Headache Disorders, third edition categorizes PDPH as a self-limiting condition; however, emerging evidence, including our findings, suggests that PDPH can have a prolonged course, challenging this traditional view.

OBJECTIVES

To elucidate the diagnostic characteristics and treatment outcomes of persistent PDPH (pPDPH), offering insights into its demographic profiles and diagnostic features.

METHODS

We executed an anonymous, web-based survey targeting individuals aged ≥18 years diagnosed with or suspected of having pPDPH. Recruitment occurred through self-help groups on Facebook. The survey comprised questions regarding diagnostic procedures, treatment regimens, outcomes, and healthcare consultation.

RESULTS

The survey achieved a response rate of 179/347 (51.6%) individuals completing the questionnaire. Cerebrospinal fluid (CSF) leaks were confirmed in nine of 179 (5.0%) cases. Signs of intracranial hypotension without a CSF leak were observed in 70/179 (39.1%) individuals. All participants underwent magnetic resonance imaging scans of the brain and spine, with computed tomography myelography performed in 113/179 (63.1%) cases. Medications, including analgesics, theophylline, and gabapentin, provided minimal short-term relief. Epidural blood patch treatments resulted in slight-to-moderate short-term improvement in 136/179 (76.0%), significant improvement in 22/179 (12.3%), and complete effectiveness in eight of 179 (4.5%) individuals. For long-term outcomes, slight-to-moderate improvement was reported by 118/179 (66.0%) individuals. Surgical interventions were carried out in 42/179 (23.5%) patients, revealing pseudomeningoceles intraoperatively in 20/42 (47.6%) individuals. After surgery, 21/42 (50.0%) of the participants experienced slight-to-moderate improvement, 12/42 (28.6%) showed more pronounced improvement, and five of the 42 (11.9%) achieved complete effectiveness.

CONCLUSION

This study underscores the complexities of managing pPDPH. The delay in diagnosis can impact the effectiveness of treatments, including epidural blood patch and surgical interventions, resulting in ongoing symptoms. This underscores the importance of tailored and adaptable treatment strategies. The findings advocate for additional research to deepen the understanding of pPDPH and improve long-term patient outcomes.

CT myelography by intrathecal injection of contrast medium though percutaneous administration route visualizes compressed cervical spinal cord in a mouse

BACKGROUND

Chronic compressive myelopathy (CCM) is a major cause of spinal cord disorders in the elderly, in which the spinal cord is compressed by bony or soft tissue structures. Although computed tomography myelography (CTM) has been clinically used for the diagnosis of CCM, a method of CTM in rodents remains to be developed.

NEW METHOD

A 50 μl Hamilton syringe attached to a disposable needle was percutaneously inserted into the subarachnoid space (cisterna magna) between the occipital bone and C1 lamina in an anesthetized adult mouse, followed by the injection of contrast medium and CT imaging.

RESULTS

CTM clearly visualized the shape of the spinal cord of intact mice and tiptoe-walking Yoshimura (Twy) mice without any health issues.

COMPARISON WITH EXISTING METHOD(S)

Unlike histology, the current method functions in live mice, directly depicts the compressed spinal cord, and provides clinically related image information. Furthermore, the intrathecal administration of contrast medium through the percutaneous route makes CTM less invasive and takes less time than a conventional intrathecal injection method.

CONCLUSIONS

The CTM method used in the present study enables clear visualization of the shape of the dural sac and spinal cord and is useful when conducting experiments on CCM and other spinal diseases in rodents.

Patterns of clinical and imaging presentations in patients with spontaneous intracranial hypotension due to spinal cerebrospinal fluid venous fistula: A single-center retrospective cross-sectional study

OBJECTIVE

To identify distinct clinical or imaging subtypes of spontaneous intracranial hypotension (SIH) due to spinal cerebrospinal fluid (CSF) venous fistula (CVF).

BACKGROUND

Spontaneous intracranial hypotension is classically understood to present clinically with an orthostatic headache and stereotyped brain magnetic resonance imaging (MRI) findings; however, most prior literature examining clinical and brain MRI features of SIH has focused on all types of spinal CSF leaks concurrently. This study aimed to evaluate whether data support the possibility of internally consistent subtypes based on brain imaging features and clinical symptoms analogous to those seen in primary headache syndromes.

METHODS

This retrospective cross-sectional single-institution study included 48 consecutive patients meeting the International Classification of Headache Disorders, 3rd edition criteria for SIH due to CVF. Clinical symptoms, pre-treatment brain MRI, and symptom duration were analyzed. Clinical and MRI data were analyzed to identify patterns and associations between symptoms and imaging findings.

RESULTS

A total of 20 males and 28 females were evaluated, with a mean (standard deviation) age of 61 (10) years. In all, 44/48 (92%) patients experienced headaches, though 18/48 (40%) did not endorse relief when flat, including six of the 48 (13%) with worsening symptoms when flat. In all, 19/48 (40%) patients reported at least one migraine symptom, and six of the 48 (13%) presented with at least one migraine symptom and had no relief when flat. Clinical symptoms clustered primarily into a "classic" presentation consisting of relief when flat, occipital head pain, comorbid neck pain, a pressure/throbbing headache quality, and an "atypical" presentation that was characterized by having several differences: less relief when flat (nine of 22 (41%) vs. 20/23 (87.0%), p = 0.002; odds ratio [OR] 0.110, 95% confidence interval [CI] 0.016-0.53), more frontal head pain (14/22 (64%) vs. one of 23 (4%), p < 0.001; OR 35.0, 95% CI 4.2-1681.0), less neck pain (two of 21 (4.5%) vs. nine of 13 (69.6%), p < 0.001; OR 0.023, 95% CI 0.0005-0.196), and more stabbing/sharp headache quality (nine of 22 (41%) vs. two of 23 (9%), p = 0.017; OR 7.0, 95% CI 1.18-75.9). Brain MRI findings clustered into three groups: those presenting with most imaging findings of SIH concurrently, those with brain sag but less pachymeningeal/venous engorgement, and those with pachymeningeal/venous engorgement but less brain sag.

CONCLUSION

This study highlights the clinical and imaging diversity among patients with SIH due to CVF, challenging the reliance on classic orthostatic headache alone for diagnosis. The findings suggest the existence of distinct SIH subtypes based on clinical and imaging presentations, underscoring the need for comprehensive evaluation in patients with suspected CVF. Future research should further elucidate the relationship between clinical symptoms and imaging findings, aiming to refine diagnostic criteria and enhance understanding of SIH's pathophysiology.

Research productivity on spontaneous intracranial hypotension: A bibliometric analysis

Introduction

Spontaneous intracranial hypotension (SIH) is an important cause of devastating headaches and caused by CSF-leaks in the spine.

Research question

The aim of this analysis was to gain an overview of the progress of research on SIH over time. The global publication landscape relating to SIH was analyzed and comparisons between regions were made.

Material and methods

A bibliometric analysis was performed by searching for research articles on SIH in PubMed published between 1983 and 2022. Countries responsible for the publications were ranked by the sum of citations. An average annual growth rate was calculated and the density of SIH publications per 100 000 physicians was determined.

Results

We identified 974 articles. In 1983 only one SIH patient was reported; in 2021 the number of patients had increased to 4230. The average annual growth rate of SIH publications during this period was 12.7%. The most common publication type were case reports (n = 570). The most common medical specialty of the first author was neurology (n = 251) followed by neurosurgery (n = 250) and radiology (n = 191). Although most publications originated from the United States of America (USA), South Korea had the highest density of SIH investigators (37.86 publications per 100 000 medical doctors). The most cited paper (296 citations) was published in 2006 in JAMA (USA).

Discussion and conclusion

Research on SIH has increased exponentially over the past four decades. The international community of SIH researchers is growing, and with it the opportunities for global networks involved in research, treatment, and patient education.

Pituitary pseudo-adenoma from cerebrospinal fluid leak in patient with Marfan syndrome

Intracranial hypotension may result in pituitary gland enlargement due to compensatory hyperaemia and venous engorgement. Spontaneous intracranial hypotension (SIH) is frequently associated with connective tissue disorders predisposing patients to dural weakening including dural ectasia and meningeal diverticula. Symptoms of SIH typically include postural headache, dizziness and tinnitus. We present a case of a female in her 20s with Marfan syndrome and a history of pituitary adenoma, who reported intractable postural headaches. Hormonal workup revealed no abnormalities, whereas brain MRI showed sequelae of intracranial hypotension. Further MRI studies revealed thoracic and lumbar meningeal diverticula with significant dural sac ectasia at the L4-S2 level. Myelogram confirmed numerous lumbar spine diverticula with cerebrospinal fluid leak at the L5 and S1 right nerve roots. The patient underwent blood patch administrations at the level of the leak with improvement of symptoms.

Cerebrospinal fluid venous fistula causing spontaneous intracranial hypotension resulting in venous sinus thrombosis and coma

Cerebrospinal fluid (CSF) fistulas have recently been recognized as a cause of spontaneous intracranial hypotension (SIH), predominantly presenting with headaches, especially positional headaches. Atypical presentations like tinnitus and cranial nerve symptoms have also been reported. SIH has been linked to venous sinus thrombosis; however, to our knowledge, no prior cases describe a CSF venous fistula causing SIH that leads to cerebral venous thrombosis and coma. We report a patient who developed progressive venous sinus thrombosis, leading to coma, and was found to have low intracranial pressure indicative of SIH. Invasive monitoring and imaging confirmed the low intracranial pressure, prompting a dynamic myelogram that revealed a T2/3 CSF venous fistula. The patient underwent transvenous embolization of the fistula, which resulted in the resolution of symptoms and almost immediate improvement in both venous thrombosis and intracranial hypotension. CSF venous fistulae as a cause of SIH is a recently recognized entity, with ongoing research into its treatment through transvenous embolization. Most documented cases focus on patients with headaches. This case highlights a novel presentation, emphasizing the importance of thorough diagnostic workup in patients with cerebral venous thrombosis. Early detection and treatment of this condition can lead to significant clinical improvement, including the resolution of coma.

Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks?

BACKGROUND AND PURPOSE

Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH.

MATERIALS AND METHODS

A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated.

RESULTS

174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky).

CONCLUSIONS

Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.

Clinical Findings, Radiological Characteristics, and Treatment Options of Spontaneous and Secondary Intracranial Hypotension: A Single-Center Experience in Turkey

Introduction  Intracranial hypotension can occur for many reasons, including trauma, surgery, congenital defects, or spontaneous rupture of the dura mater. Symptoms appear long before cerebrospinal fluid (CSF) leaks are diagnosed. Treatment procedures include a variety of conservative and invasive techniques appropriate to the nature of the etiological cause and the severity of the disease. In this cross-sectional study, we aimed to investigate the clinical and imaging features and treatment options of intracranial hypotension patients and to compare them in terms of different etiologies. Methods The data from intracranial hypotension patients were analyzed retrospectively. Symptomatology, neurological findings, and radiological features were compared between patients with spontaneous intracranial hypotension (SIH) and those with secondary causes. Radiological outcomes of conservative treatment and epidural blood patch (EBP) were also evaluated for both groups. Results Of the 30 patients, 23 were female. In 14 of the patients (46.6%), a possible cause of CSF leakage was detected. Compared to intracranial hypotension patients with a secondary cause, SIH patients complained of posterior neck and shoulder pain more frequently (p=0.014, p=0.006). MRI features did not differ significantly when the two groups were compared (p>0.05). The first and sixth-month follow-up MRIs of patients treated with EBP or a conservative approach showed similar improvement rates (p=0.788). Conclusions There was no significant difference in radiological recovery time between conservative treatment and EBP in patients with intracranial hypotension. Radiological recovery times are similar in patients with secondary intracranial hypotension and SIH.

"Empty Cyst Sign" Appearance of CSF-Venous Fistula on Digital Spinal Myelography

Cerebrospinal fluid venous fistulas (CSF-VFs) are an uncommon, yet increasingly recognized, cause of spontaneous intracranial hypotension.1-5 The workup involves magnetic resonance imaging (MRI) of the brain with and without contrast and MRI of the neuroaxis without contrast before dynamic myelography, either computed tomography or digital subtraction.6 The present case of an older woman with symptomatic intracranial hypotension is notable for the specific appearance of CSF-VFs on digital spinal myelography (Video 1). Among her numerous perineural cysts, it was the "disappearing" or "empty" cyst from which the fistula originated. The diagnosis was made using a second lateral fluoroscopy view, not typically used in digital spinal myelography, which demonstrated emptying of contrast from the T6 perineural cyst into the segmental vein at this level, or the "empty cyst sign." The patient then underwent transvenous onyx embolization with resolution of her orthostatic headaches and improvement of contrast-enhanced MRI of the brain with the Bern score decreasing from 7 to 0 at 3 months of follow-up.7 Because transvenous embolization of CSF-VFs is a relatively new procedure, the long-term outcomes of the procedure are not yet known.

Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening

PURPOSE

To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility.

METHODS

In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen's kappa statistics, interobserver agreement was assessed.

RESULTS

In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39).

CONCLUSION

The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.