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Liaw V, McCreary M, Friedman DI. Quality of Life in Patients With Confirmed and Suspected Spinal CSF Leaks. Neurology 2023; 101:e2411-e2422. [PMID: 37816637 PMCID: PMC10752647 DOI: 10.1212/wnl.0000000000207763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Spontaneous intracranial hypotension (SIH) is a debilitating condition typically producing orthostatic headache limiting upright time. SIH is often difficult to diagnose and treat, negatively affecting quality of life (QoL) in patients with the disorder. We studied QoL in patients with confirmed and suspected SIH using standardized instruments, including suicidality. METHODS We performed a cross-sectional survey of adult patients with confirmed and clinically suspected SIH evaluated in our Headache and Facial Pain Program from 2016 to 2022. Using an online data collection tool (REDCap V 11.2.2), participants completed validated questionnaires assessing general well-being (SF-36), depression (PHQ-9), generalized anxiety disorder-7 (GAD-7), spiritual well-being during chronic illness therapy (FACIT-Sp-12), and headache impact (HIT-6). Subsequently, we interviewed willing participants to administer the Columbia-Suicide Severity Rating Scale (C-SSRS) assessing suicidal behavior and ideation. RESULTS A total of 234 patients met inclusion criteria and were invited to participate in the study, and 95 patients (59 confirmed and 36 clinically suspected) completed the questionnaires. The average age of the cohort was 51.1 years (SD: 15.5), predominantly female (69.5%), White (91.6%), and married (69.5%). Three-quarters (74.5%) scored within the most severe headache category (HIT-6). SF-36 scores were significantly inferior (p < 0.0001) to the general population and lower than reported values for patients with multiple sclerosis and idiopathic intracranial hypertension. Almost half (49.1%) of respondents scored in the moderate depression range or worse (>10), and 25.4% scored with moderate anxiety or worse (>10). FACIT-Sp-12 scores were significantly worse (p < 0.0001) in symptomatic participants than in the validation cohorts of patients with AIDS and cancer. Of the 67 respondents who completed the C-SSRS, more than half (64.2%) endorsed a wish to be dead, and 22.4% had demonstrated suicidal behavior. Patients with symptom-free SIH (n = 22) scored significantly better than symptomatic patients, comparable with the general population. DISCUSSION Based on our single-center cohort, SIH is associated with severe headache pain and high rates of depression, anxiety, and disability, affecting basic activities of daily living. Individuals with confirmed and suspected spinal CSF leaks scored similarly on these measures including suicidality. Outcomes were comparable with the general population after successful treatment or spontaneous remission. Improved identification and treatment of SIH are imperative to improve patients' QoL.
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Affiliation(s)
- Victor Liaw
- From the Department of Neurology (M.M., D.I.F.), University of Texas Southwestern Medical Center (V.L.), Dallas; and Department of Ophthalmology (D.I.F.), University of Texas Southwestern, Dallas
| | - Morgan McCreary
- From the Department of Neurology (M.M., D.I.F.), University of Texas Southwestern Medical Center (V.L.), Dallas; and Department of Ophthalmology (D.I.F.), University of Texas Southwestern, Dallas
| | - Deborah I Friedman
- From the Department of Neurology (M.M., D.I.F.), University of Texas Southwestern Medical Center (V.L.), Dallas; and Department of Ophthalmology (D.I.F.), University of Texas Southwestern, Dallas.
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Bonomo G, Bussone G, Gans A, Iess G, Bonomo R, Restelli F, Falco J, Mazzapicchi E, Stanziano M, Amato A, Broggi M, Acerbi F, Ferroli P, Schiariti M. Small spheno-ethmoidal meningoencephalocele versus ethmoidal mucocele in spontaneous intracranial hypotension. BRAIN & SPINE 2023; 3:102676. [PMID: 38021026 PMCID: PMC10668106 DOI: 10.1016/j.bas.2023.102676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/07/2023] [Accepted: 09/17/2023] [Indexed: 12/01/2023]
Abstract
Background Meningoencephalocele is defined as an abnormal sac of brain tissue and meninges extending beyond natural skull margins, often leading to cerebrospinal fluid (CSF) leakage. When this condition arises in the spheno-ethmoidal region, the diagnosis becomes more challenging as it can be mistaken for other nasal pathologies, such as mucocele. Research question We show in this case report a non-congenital sphenoethmoidal meningoencephalocele causing rhinoliquoral fistula and spontaneous intracranial hypotension. Results this 65-year-old woman presented with sporadic rhinoliquorrhoea associated with orthostatic headache, nausea and dizziness. Brain MRI revealed a small lesion of an ethmoidal sinus, which was successfully treated with endoscopic endonasal surgery. Histology confirmed the presence of meningoencephalic tissue positive for S100 protein on immunohistochemistry. Conclusions When dealing with lesions of the paranasal sinuses in contact with the anterior skull base, rhinoliquorrhoea presence suggests meningoencephalocele. In dubious cases, a proper workup, including a thorough clinical history and neurological examination, specific imaging, and a direct search of CSF-like markers, is essential to support the differential diagnosis. In such cases, a transnasal endoscopic surgical approach is recommended to obtain a final histological diagnosis and to perform eventual dural plastic surgery.
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Affiliation(s)
- Giulio Bonomo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Gennaro Bussone
- Department of Neurology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Alessandro Gans
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Guglielmo Iess
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Roberta Bonomo
- Department of Neurology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- School of Medicine and Surgery, Kore University of Enna, Enna, Italy
| | - Francesco Restelli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Elio Mazzapicchi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Mario Stanziano
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Neurosciences Department “Rita Levi Montalcini”, University of Turin, Turin, Italy
| | - Alessia Amato
- Department of Child Neuropsychiatry, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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Houk JL, Morrison S, Peskoe S, Amrhein TJ, Kranz PG. Validity of the Bern Score as a Surrogate Marker of Clinical Severity in Patients with Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2023; 44:1096-1100. [PMID: 37562827 PMCID: PMC10494944 DOI: 10.3174/ajnr.a7962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND PURPOSE The Bern score is a quantitative scale characterizing brain MR imaging changes in spontaneous intracranial hypotension. Higher scores are associated with more abnormalities on brain MR imaging, raising the question of whether the score can serve as a measure of disease severity. However, the relationship between clinical symptom severity and the Bern score has not been evaluated. Our purpose was to assess correlations between Bern scores and clinical headache severity in spontaneous intracranial hypotension. MATERIALS AND METHODS This study was a single-center, retrospective cohort of patients satisfying the International Classification of Headache Disorders-3 criteria for spontaneous intracranial hypotension. Fifty-seven patients who completed a pretreatment headache severity questionnaire (Headache Impact Test-6) and had pretreatment brain MR imaging evidence of spontaneous intracranial hypotension were included. Pearson correlation coefficients (ρ) for the Headache Impact Test-6 and Bern scores were calculated. Receiver operating characteristic curves were used to assess the ability of Bern scores to discriminate among categories of headache severity. RESULTS We found low correlations between clinical headache severity and Bern scores (ρ = 0.139; 95% CI, -0.127-0.385). Subgroup analyses examining the timing of brain MR imaging, symptom duration, and prior epidural blood patch showed negligible-to-weak correlations in all subgroups. Receiver operating characteristic analysis found that the Bern score poorly discriminated subjects with greater headache severity from those with lower severity. CONCLUSIONS Pretreatment Bern scores show a low correlation with headache severity in patients with spontaneous intracranial hypotension. This finding suggests that brain imaging findings as reflected by Bern scores may not reliably reflect clinical severity and should not replace clinical metrics for outcome assessment.
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Affiliation(s)
- J L Houk
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - S Morrison
- Department of Biostatistics and Bioinformatics (S.M., S.P.), Duke University School of Medicine, Durham, North Carolina
| | - S Peskoe
- Department of Biostatistics and Bioinformatics (S.M., S.P.), Duke University School of Medicine, Durham, North Carolina
| | - T J Amrhein
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - P G Kranz
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
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Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed. AREAS COVERED The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes. EXPERT OPINION The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.
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Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Mamlouk MD, Shen PY, Dahlin BC. Headache response after
CT‐guided
fibrin glue occlusion of
CSF‐venous
fistulas. Headache 2022; 62:1007-1018. [DOI: 10.1111/head.14379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/21/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Mark D. Mamlouk
- Department of Radiology The Permanente Medical Group, Kaiser Permanente Medical Center Santa Clara California USA
- Department of Radiology and Biomedical Imaging University of California San Francisco California USA
| | - Peter Y. Shen
- Department of Radiology The Permanente Medical Group, Kaiser Permanente Medical Center Santa Clara California USA
| | - Brian C. Dahlin
- Department of Radiology The Permanente Medical Group, Kaiser Permanente Medical Center Sacramento California USA
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Spontaneous intracranial hypotension: searching for the CSF leak. Lancet Neurol 2022; 21:369-380. [DOI: 10.1016/s1474-4422(21)00423-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
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Casanova A, Entz L, Weinmann S, Wanke I, Reisch R. Bilateral subdural hematoma caused by spontaneous intracranial hypotension originating from a discogenic microspur successfully treated with duraplasty: A case report. BRAIN AND SPINE 2022; 2:100879. [PMID: 36248145 PMCID: PMC9562247 DOI: 10.1016/j.bas.2022.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 11/25/2022]
Abstract
Introduction Discogenic microspurs are calcified outgrowths from the intervertebral disc which can perforate the dura, causing a leak of cerebrospinal fluid (CSF). Spontaneous leaks of the CSF present a recognized cause of spontaneous intracranial hypotension (SIH). Moreover, subdural hematomas (SDH) are a potentially severe complication of SIH. Research question We present a case of a bilateral subdural hematoma without orthostatic headaches caused by a discogenic microspur protruding from the T1-2 intervertebral disc. The microspur is conjectured to be the culprit of the leak by ventrally perforating the dura and catalyzing the causal chain leading to the formation of the subdural hemorrhage. Material and methods A 79-year woman noticed a progressive gait disturbance accompanied by a decline of short-term memory over several months without experiencing orthostatic headaches. Magnetic resonance imaging (MRI) showed extensive bilateral subdural fronto-parietal hematoma, signs of CSF hypotension (dilated venous compartments), and computed tomography (CT) myelography revealed a CSF leak originating at the T1-2 level. Results The leakage site was treated with microsurgical duraplasty leading to a regression of the symptoms and complete resolution of the subdural hematomas within five postoperative months. Discussion and conclusion Discogenic microspurs can perforate the dura causing a CSF leak, leading to spontaneous intracranial hypotension, finally resulting in a bilateral subdural hematoma. This constellation of symptoms does not necessarily induce orthostatic headaches and can be treated with microsurgical duraplasty. Discogenic microspur perforating the dura and inducing a liquor leak. Discogenic microspur leading to spontaneous intracranial hypotension. Discogenic microspur leading to bilateral subdural hematoma. Liquor leak treated by microsurgical duraplasty. Bilateral subdural hematoma retraction after microsurgical duraplasty.
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Affiliation(s)
- Andrea Casanova
- University of Zurich, Rämistrasse 71, 8006, Zurich, Switzerland
- Department of Emergency Medicine, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
- Corresponding author. University of Zurich, Rämistrasse 71, 8006, Zurich, Switzerland.
| | - László Entz
- Department of Neurosurgery, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
| | - Simon Weinmann
- Department of Emergency Medicine, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
| | - Isabel Wanke
- Department of Radiology, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
| | - Robert Reisch
- Department of Neurosurgery, Hirslanden Klinik, Witellikerstrasse 40, 8032, Zurich, Switzerland
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