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Volz F, El Rahal A, Fung C, Shah M, Lützen N, Urbach H, Beck J, Wolf K. Don't delay, but don't despair: symptom duration, comorbidity and outcome after closure of spinal cerebrospinal fluid leaks. J Neurol 2024; 271:2776-2786. [PMID: 38409537 PMCID: PMC11055789 DOI: 10.1007/s00415-024-12242-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Microsurgical sealing of spinal cerebrospinal fluid (CSF) leaks is a viable treatment option in spontaneous intracranial hypotension (SIH). Several factors may influence the outcome, with symptom duration probably the most modifiable variable. METHODS Patients with closure of spinal CSF leaks between September 2020 and March 2023 and a follow-up period of 6 months were included in this retrospective single-center study. Pre- and postoperative scores for impact of headaches (Headache Impact Test, HIT-6) and quality of life (QoL, EQ-5D-5L) were systematically collected. Multiple regression modelling and subgroup analyses for different symptom durations and comorbidities were performed for these outcomes. RESULTS One hundred patients (61% female, median age 43.5 years) were included. Six months postoperatively, there was significant improvement in headache impact (HIT-6: 66 (IQR 62-69) to 52 (IQR 40-61, p < 0.001) and QoL (EQ-5D-5L VAS: 40 (IQR 30-60) to 79 (IQR 60-90); EQ-5D-5L Index: 0.67 (IQR 0.35-0.8) to 0.91 (IQR 0.8-0.94, p < 0.001, respectively). Subgroup analysis for a symptom duration above (74%) and below 90 days (26%) and comorbidity, as well as multiple regression analysis, revealed a trend in favor of early treatment and lower comorbidity. However, even after a prolonged symptom duration, improvements were significant. CONCLUSION As patients with shorter symptom duration show a trend for a better outcome, our results promote a timely diagnosis and treatment in SIH patients. However, a significant postoperative improvement can still be expected even after a prolonged symptom duration.
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Affiliation(s)
- Florian Volz
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
- Department of Neurosurgery, Lindenhofspital, Bern, Switzerland
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
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Jurcau MC, Jurcau A, Hogea VO, Diaconu RG. Spontaneous Intracranial Hypotension: Case Report and Update on Diagnosis and Treatment. Diagnostics (Basel) 2024; 14:881. [PMID: 38732297 PMCID: PMC11083259 DOI: 10.3390/diagnostics14090881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Spontaneous intracranial hypotension (SIH) is an important cause of daily headaches that occur in young and middle-aged, active persons and is often misdiagnosed, leading to prolonged inactivity and rather high healthcare expenditures. Its diagnosis requires a high degree of clinical suspicion and careful interpretation of imaging studies. We present a case of SIH, which was successfully treated but which posed serious diagnostic challenges, ranging from cerebro-vascular disease and meningitis to granulomatous diseases, and for whom every therapeutic attempt just worsened the patient's condition until we finally reached the correct diagnosis. To raise awareness of this condition, we also present an updated overview of the clinical picture, evaluation, and treatment options for SIH.
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Affiliation(s)
- Maria Carolina Jurcau
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.C.J.); (V.O.H.); (R.G.D.)
| | - Anamaria Jurcau
- Department of Psycho-Neurosciences and Rehabilitation, University of Oradea, 410087 Oradea, Romania
| | - Vlad Octavian Hogea
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.C.J.); (V.O.H.); (R.G.D.)
| | - Razvan Gabriel Diaconu
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.C.J.); (V.O.H.); (R.G.D.)
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Wolf K, Volz F, Lützen N, Mast H, Reisert M, Rahal AE, Fung C, Shah MJ, Beck J, Urbach H. Non-invasive biomarkers for spontaneous intracranial hypotension (SIH) through phase-contrast MRI. J Neurol 2024:10.1007/s00415-024-12365-6. [PMID: 38643444 DOI: 10.1007/s00415-024-12365-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND AND OBJECTIVE Spontaneous intracranial hypotension (SIH) is an underdiagnosed disease. To depict the accurate diagnosis can be demanding; especially the detection of CSF-venous fistulas poses many challenges. Potential dynamic biomarkers have been identified through non-invasive phase-contrast MRI in a limited subset of SIH patients with evidence of spinal longitudinal extradural collection. This study aimed to explore these biomarkers related to spinal cord motion and CSF velocities in a broader SIH cohort. METHODS A retrospective, monocentric pooled-data analysis was conducted of patients suspected to suffer from SIH who underwent phase-contrast MRI for spinal cord and CSF velocity measurements at segment C2/C3 referred to a tertiary center between February 2022 and June 2023. Velocity ranges (mm/s), total displacement (mm), and further derivatives were assessed and compared to data from the database of 70 healthy controls. RESULTS In 117 patients, a leak was located (54% ventral leak, 20% lateral leak, 20% CSF-venous fistulas, 6% sacral leaks). SIH patients showed larger spinal cord and CSF velocities than healthy controls: e.g., velocity range 7.6 ± 3 mm/s vs. 5.6 ± 1.4 mm/s, 56 ± 21 mm/s vs. 42 ± 10 mm/s, p < 0.001, respectively. Patients with lateral leaks and CSF-venous fistulas exhibited an exceptionally heightened level of spinal cord motion (e.g., velocity range 8.4 ± 3.3 mm/s; 8.2 ± 3.1 mm/s vs. 5.6 ± 1.4 mm/s, p < 0.001, respectively). CONCLUSION Phase-contrast MRI might become a valuable tool for SIH diagnosis, especially in patients with CSF-venous fistulas without evidence of spinal extradural fluid collection.
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Affiliation(s)
- Katharina Wolf
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Florian Volz
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hansjoerg Mast
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Department of Radiology, Medical Physics, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
- Department of Neurosurgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Mukesch J Shah
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Benson JC, Mark IT, Madhavan AA, Johnson-Tesch B, Diehn FE, Carr CM, Kim DK, Brinjikji W, Verdoorn JT. Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks? Neuroradiol J 2024:19714009241242645. [PMID: 38525966 DOI: 10.1177/19714009241242645] [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: 03/26/2024] Open
Abstract
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.
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Affiliation(s)
| | - Ian T Mark
- Department of Radiology, Mayo Clinic, USA
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5
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Pascaud J, Redon S, Elzière M, Donnet A. Real-life study of the use of oto-acoustic emissions in the diagnosis of intracranial hypotension. Rev Neurol (Paris) 2024; 180:154-162. [PMID: 37827931 DOI: 10.1016/j.neurol.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The diagnosis of spontaneous or post-traumatic intracranial hypotension (IH) mainly relies on clinical features and neuro-imaging. However, the results of brain and spine magnetic resonance imaging are not always contributive. There is an interest for other non-invasive procedures, able to confirm or refute the diagnosis. The use of oto-acoustic emissions (OAE) was previously reported on isolated cases of IH associated with endolymphatic hydrops (ELH). The aim of this study was to assess the real-life utilization of this electrophysiological method in a larger population of suspected IH. METHODS A retro-prospective cohort study was conducted from November 2013 to July 2022 in patients with a suspected or doubtful diagnosis of IH. They were assessed for ELH by recording bilateral distortion product of oto-acoustic emissions (DPOAE) in sitting then in supine position. RESULTS Among the 32 patients assessed, the diagnostic of IH was confirmed in 18 patients. An ELH was shown in 15 of them (83%), but also in seven other patients. They had several differential diagnoses: chronic migraine, Chiari malformation, rebound intracranial hypertension and perilymph fistula. CONCLUSIONS This procedure seems to be insufficient to exclude differential diagnosis when intracranial hypotension is suspected.
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Affiliation(s)
- J Pascaud
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, CHU Timone, AP-HM, Marseille, France
| | - S Redon
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, CHU Timone, AP-HM, Marseille, France.
| | - M Elzière
- Vertigo Center, European Hospital, Marseille, France
| | - A Donnet
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, CHU Timone, AP-HM, Marseille, France; INSERM U-1107, CHU de Clermont-Ferrand, Clermont-Ferrand, France
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6
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Orscelik A, Cutsforth-Gregory JK, Madhavan A, Senol YC, Kobeissi H, Belge Bilgin G, Bilgin C, Kallmes DF, Brinjikji W. Endovascular Embolization Techniques for Cerebrospinal Fluid-Venous Fistula in the Treatment of Spontaneous Intracranial Hypotension. Radiol Clin North Am 2024; 62:345-354. [PMID: 38272626 DOI: 10.1016/j.rcl.2023.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Cerebrospinal fluid-venous fistula (CVF) is an important cause of spontaneous intracranial hypotension (SIH), a condition characterized by low cerebrospinal fluid (CSF) volume and orthostatic headaches. The pathogenesis of CVF is thought to be direct connection of the spinal dura to one or more veins in the epidural space, allowing unregulated flow of CSF into the venous system. Herein, we provide a comprehensive review of the endovascular management of CVF in patients with SIH. We also focus on the various techniques and devices used in endovascular treatment, as well as the pathogenesis, diagnosis, and alternative treatment options of CVF.
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Affiliation(s)
| | | | - Ajay Madhavan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Yigit Can Senol
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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7
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García-Ull J, González-García N, Torres-Ferrús M, García-Azorín D, Molina-Martínez IFJ, Beltrán-Blasco I, Santos-Lasaosa S, Latorre G, Gago-Veiga AB, Láinez JM, Porta-Etessam J, Nieves-Castellanos C, Mínguez-Olaondo A, López-Bravo A, Quintas S, Morollón N, Díaz-Insa S, Belvís R, Irimia P. Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group. Neurologia 2024:S2173-5808(24)00048-8. [PMID: 38431253 DOI: 10.1016/j.nrleng.2024.02.009] [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: 03/05/2024] Open
Abstract
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.
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Affiliation(s)
- J García-Ull
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain.
| | - N González-García
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain
| | - M Torres-Ferrús
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - D García-Azorín
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Spain
| | - I F J Molina-Martínez
- Servicio de Neurología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - I Beltrán-Blasco
- Unidad de Cefaleas, Servicio de Neurología, Hospital General Universitario Dr. Balmis de Alicante, Spain
| | - S Santos-Lasaosa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - G Latorre
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - A B Gago-Veiga
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
| | - J M Láinez
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - J Porta-Etessam
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - C Nieves-Castellanos
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario y Politécnico la Fe, Instituto de Investigación Sanitaria la Fe, Valencia, Spain
| | - A Mínguez-Olaondo
- Servicio de Neurología, Hospital Universitario Donostia, Instituto de Investigación Biodonostia, Athenea Neuroclinicis, Donostia, Facultad de Ciencias de la Salud, Universidad de Deusto, Bilbao, Spain
| | - A López-Bravo
- Servicio de Neurología, Hospital Reina Sofía de Tudela, Navarra, Spain
| | - S Quintas
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
| | - N Morollón
- Unidas de Cefaleas, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - S Díaz-Insa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario y Politécnico la Fe, Instituto de Investigación Sanitaria la Fe, Valencia, Spain
| | - R Belvís
- Unidas de Cefaleas, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - P Irimia
- Unidad de Cefaleas, Servicio de Neurología, Clínica Universitaria de Navarra, Pamplona, Spain
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Cirillo L, Verna F, Princiotta C, Dall’Olio M, Rustici A, Bortolotti C, Badaloni F, Mascarella D, Cortelli P, Cevoli S. Spontaneous Intracranial Hypotension and Subdural Hematomas Treatment Management Using MMA Embolization and Target Blood Patch: A Case Report. Life (Basel) 2024; 14:250. [PMID: 38398759 PMCID: PMC10890540 DOI: 10.3390/life14020250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
We report a patient suffering from spontaneous intracranial hypotension (SIH) who, following a non-selective lumbar blood patch, returned to his healthcare provider with severe symptoms of neurological deficits. It was subsequently discovered that the aforementioned deficits were due to a bilateral subdural hematoma, and an emergency surgical drainage of the hematoma has been performed. However, the hematoma reformed and potential cerebrospinal fluid leakage was consequently investigated through myelography. Following the diagnostic finding of a venous diverticulum, a selective blood patch was executed in the affected area, and in order to stabilize the hematoma, an embolization of the middle meningeal arteries was performed. The combination of such operations allowed for the resorption of the hematoma and the improvement of neurological symptoms.
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Affiliation(s)
- Luigi Cirillo
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Francesca Verna
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Ciro Princiotta
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
| | - Massimo Dall’Olio
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
| | - Arianna Rustici
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Carlo Bortolotti
- UO Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (C.B.); (F.B.)
| | - Filippo Badaloni
- UO Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (C.B.); (F.B.)
| | - Davide Mascarella
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
| | - Pietro Cortelli
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
| | - Sabina Cevoli
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
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9
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Liao L, Tonnelet R, Schmitt E, Planel S, Zhu F, Muszynski P, Harsan O, Anxionnat R, Bracard S, Braun M. CT-guided percutaneous cyanoacrylate injection targeting the spinal cerebrospinal fluid leak: a potential therapeutic option for spontaneous intracranial hypotension. J Neurointerv Surg 2024; 16:261-265. [PMID: 36927657 DOI: 10.1136/jnis-2022-020004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND We report the first case series of spontaneous intracranial hypotension (SIH) patients who underwent CT-guided percutaneous cyanoacrylate injection targeting the cerebrospinal fluid (CSF) leak. METHODS A retrospective analysis was performed for all consecutive cases of SIH patients with CSF leak confirmed on CT myelography, treated by CT-guided percutaneous cyanoacrylate injection at our institution from 2016 to 2022. On pretreatment brain and spine MRIs, we analyzed signs of SIH according to the Bern score, and dichotomized cases into positive/negative for spinal longitudinal extradural CSF collection (SLEC-P or SLEC-N). The leaks detected on CT myelography were classified into three types according to Schievink et al. We collected the Headache Impact Test 6 (HIT-6) scores throughout a 6-month follow-up, with a brain CT scan at each visit. RESULTS 11 patients were included (mean age 48.4 years, six men). Five SLEC-P type 1, three SLEC-P type 2, and three SLEC-N type 3 leaks were identified. All patients had significant signs of SIH on pretreatment brain MRI (mean Bern score 7.8±1.1). Six patients underwent a foraminal puncture, and five patients had a cervical epidural approach. Two patients experienced mild and transient locoregional pain after cervical epidural injection. Mean HIT-6 score at baseline was 66.8±3.2 and at the 6-month follow-up was 38±3.6 (P<0.001). All patients achieved improvement in their symptoms, with 82% of them (9/11) having complete resolution of headaches and SIH findings on CT scans at 6 months. No clinical worsening or recurrence was observed. CONCLUSIONS CT-guided percutaneous cyanoacrylate injection may be a potential therapeutic option for the different types of CSF leak causing SIH.
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Affiliation(s)
- Liang Liao
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- LORIA, Vandoeuvre-les-Nancy, Grand Est, France
| | - Romain Tonnelet
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- University of Lorraine, Nancy, Grand Est, France
| | - Emmanuelle Schmitt
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
| | - Sophie Planel
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
| | - François Zhu
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- University of Lorraine, Nancy, Grand Est, France
| | - Patricio Muszynski
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- Instituto Oulton, Cordoba, Argentina
| | - Oana Harsan
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- University of Lorraine, Nancy, Grand Est, France
| | - René Anxionnat
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- University of Lorraine, Nancy, Grand Est, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- University of Lorraine, Nancy, Grand Est, France
| | - Marc Braun
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
- University of Lorraine, Nancy, Grand Est, France
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10
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Coşarcan SK, Erçelen Ö. The cervical blood patch: A therapeutic "miraculous" for cerebrospinal fluid leaks: A case report. Medicine (Baltimore) 2024; 103:e37035. [PMID: 38306558 PMCID: PMC10843348 DOI: 10.1097/md.0000000000037035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/03/2024] [Indexed: 02/04/2024] Open
Abstract
RATIONALE Cerebrospinal fluid (CSF) leaks, arising from abnormal openings in the protective layers surrounding the spinal cord and brain, are a significant medical concern. These leaks, triggered by various factors including trauma, medical interventions, or spontaneous rupture, lead to the draining of CSF-an essential fluid safeguarding the nervous system. A classic symptom of CSF leaks is an incapacitating headache exacerbated by sitting or standing but relieved by lying down. Spontaneous intracranial hypotension (SIH) denotes the clinical condition marked by postural headaches due to spontaneous CSF leakage and hypotension, often misdiagnosed or underdiagnosed. While orthostatic headaches are the hallmark, SIH may manifest with an array of symptoms including nausea, tinnitus, hearing loss, visual disturbances, and dizziness. Treatment options encompass conservative measures, epidural blood patches (EBP), and surgery, with EBP being the primary intervention. PATIENT CONCERN The patient did not express any specific concerns regarding their medical diagnosis. However, they did harbor apprehensions that their condition might necessitate surgical intervention in the future. DIAGNOSIS The patient had been treated with antibiotics with a pre-diagnosis of sinusitis and was admitted to the neurology department of our hospital when his symptoms failed to improve. Cranial magnetic resonance imaging was interpreted as thickening of the dural surfaces and increased contrast uptake, thought to be due to intracranial hypotension. Cranial MR angiography was normal. Full-spine magnetic resonance imaging revealed a micro-spur at the C2 to 3 level and the T1 to 2 level in the posterior part of the corpus. INTERVENTIONS The cervical EBP was performed in the prone position under fluoroscopic guidance. There were no complications. OUTCOMES The patient was invited for follow-up 1 week after the procedure, and control examination was normal. LESSONS SIH poses a diagnostic challenge due to its diverse clinical presentation and necessitates precise imaging for effective intervention. Cervical EBP emerges as a promising treatment modality, offering relief and improved quality of life for individuals grappling with this condition. However, clinicians must carefully assess patients and discuss potential risks and benefits before opting for cervical blood patches.
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Affiliation(s)
- Sami Kaan Coşarcan
- VKV American Hospital, Department of Anesthesiology, Istanbul, Turkey
- Koç University, School of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Ömür Erçelen
- Koç University, School of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
- VKV American Hospital, Department of Anesthesiology and Algology Clinic, Istanbul, Turkey
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11
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Chen L, Wu H, Hu X, Ying G. Acquired tonsillar herniation related to spontaneous intracranial hypotension: case reports. Front Neurol 2024; 15:1309718. [PMID: 38327627 PMCID: PMC10847289 DOI: 10.3389/fneur.2024.1309718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Background Acquired prolapse of the cerebellar tonsils in spontaneous intracranial hypotension (SIH) patients is rare. This study aims to evaluate neuroimaging changes of acquired prolapse of the cerebellar tonsils below the foramen magnum in SIH patients due to spontaneous spinal cerebrospinal fluid leakage, which was treated by targeted epidural blood patches (EBP). Methods We retrospectively reviewed clinical and neuroimaging characteristics of 5 cases of SIH with acquired prolapse of the cerebellar tonsils that received targeted EBP in our institution from January 2013 to December 2016. Results Of these SIH patients, all of them suffered from an orthostatic headache. Initial cranial MRI demonstrated descent of the cerebellar tonsils ≥5 mm. Intrathecal gadolinium-enhanced spinal MR myelography and/or spinal MR hydrography were performed to evaluate the level of spinal cerebrospinal fluid leakage. Symptoms were alleviated in all 5 patients after two (n = 4), or three (n = 1) targeted EBP during hospitalization. Follow-up cranial MRI revealed that the descent of cerebellar tonsils was reversed after EBP treatment. Conclusion Acquired tonsillar herniation can occur in patients with SIH and spinal cerebrospinal fluid leakage. Symptoms of these patients may be resolved and radiologic findings may be reversed after EBP treatment.
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Affiliation(s)
- Lili Chen
- Department of Neurology, Xiasha Campus, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haijian Wu
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xingyue Hu
- Department of Neurology, Xiasha Campus, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guangyu Ying
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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12
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Goddu Govindappa SK, Adiga CP, Kumar S, Goolahally LN, Kumar S. Spontaneous Intracranial Hypotension: A Review of Neuroimaging and Current Concepts. Indian J Radiol Imaging 2024; 34:128-138. [PMID: 38106851 PMCID: PMC10723964 DOI: 10.1055/s-0043-1774301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Spontaneous intracranial hypotension (SICH) is the emerging cause of orthostatic headache as it has been better recognized in recent years. SICH happens due to spinal cerebrospinal fluid (CSF) leak; however, the manifestations are predominantly cranial and hence imaging in SICH includes brain and spine. There are few characteristic brain imaging features to be concerned about to diagnose SICH in patients with vague symptoms or low clinical suspicion. Spine screening is recommended in these patients to assess spinal CSF leaks. While neuroradiologists play a significant role from the time of diagnosis to treatment of SICH, there is a need for all the general radiologists to be aware of the condition. Computed tomography myelogram and digital subtraction myelogram are performed for diagnostic and therapeutic management of SICH. There is a known risk for SICH recurrence in patients with sagittal longitudinal epidural collection and hence, targeted blood patch should be used instead of blind patch. Most importantly, slow mobilization is recommended following the patch to avoid recurrence.
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Affiliation(s)
| | | | - Savith Kumar
- Department of Radiology, Apollo Hospitals, Sheshadripuram, Bangalore, Karnataka, India
| | | | - Sujit Kumar
- Department of Neurology, Apollo Hospitals, Sheshadripuram, Bangalore, Karnataka, India
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13
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Yoo HJ. [Spinal Presentation of Spontaneous Intracranial Hypotension]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:24-35. [PMID: 38362391 PMCID: PMC10864159 DOI: 10.3348/jksr.2023.0151] [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: 12/04/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 02/17/2024]
Abstract
Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and heightened awareness. Many prior studies have reported the characteristic brain MRI findings of SIH. However, recently, focus has shifted to spinal MRI, as SIH is believed to be caused by leakage of cerebrospinal fluid from the spinal dural sac. Advanced techniques such as ultrafast CT myelography and digital subtraction myelography have emerged as useful technique to identify the site of cerebrospinal fluid leakage. In this review, we discuss the diagnosis, spinal MRI findings, imaging techniques, and treatment of SIH.
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Murphy K, Nasralla M, Pron G, Almohaimede K, Schievink W. Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals. Neuroradiology 2024; 66:1-30. [PMID: 37828278 PMCID: PMC10761484 DOI: 10.1007/s00234-023-03226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/19/2023] [Indexed: 10/14/2023]
Abstract
Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts.
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Affiliation(s)
- Kieran Murphy
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
| | - Mehran Nasralla
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Gaylene Pron
- Dalla Lana School of Public Health, Institute Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Khaled Almohaimede
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Wouter Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, 6Th Floor, Los Angeles, CA, 90048, USA
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15
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Schartz D, Ellens N, Ismail R, Houk C, Kessler A, Ellika S, Bender MT. Prevalence of SLEC-negative spontaneous intracranial hypotension in patients with spinal nerve root sleeve diverticula on MRI. Neuroradiol J 2023; 36:736-739. [PMID: 37589060 PMCID: PMC10649535 DOI: 10.1177/19714009231196467] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
PURPOSE While there is thought to be an association between spinal nerve root diverticula (NRD) and spontaneous intracranial hypotension (SIH) without a spinal longitudinal epidural collection (SLEC), it remains unclear what the overall prevalence of SLEC-negative SIH is in patients with NRD on MRI. METHODS Spine MRI imaging reports from our single institution were electronically screened for instances of NRD over a 9-year period (2016-2023). From these cases, patients with brain MRIs consistent with SIH were also identified. Subsequently, the overall proportion of SLEC-negative SIH was determined as a function of total cases with NRD based on spinal level. RESULTS In total, 83,843 patients with spinal MRIs were screened which identified 4174 (4.97%) with NRD. From these, there were 1203 cervical, 622 thoracic, and 2979 lumbosacral spine MRIs. In total, 16 patients (0.38%; Standard Error [SE]: 0.48%-0.28%) had a brain MRI compatible with SLEC-negative SIH and met ICHD-3 criteria. Patients with cervical NRD had SIH in 2 cases (0.16%; SE: 0.27%-0.05%). SLEC-negative SIH was present in 11 patients with lumbosacral NRD (0.34%; SE: 0.44%-0.24%). In patients with diverticula in the thoracic spine, 14 (2.3%; SE: 2.8%-1.8%) had SLEC-negative SIH. SLEC-negative SIH was significantly more prevalent in patients with thoracic diverticula compared to those with cervical (p<.0001) or lumbosacral NRD (p<.0001). CONCLUSION In patients with spinal NRD, concurrent SLEC-negative SIH is present in approximately 0.38% of patients, suggesting that in the vast majority of cases, they are an incidental finding. However, SIH is present in approximately 2.3% of patients with thoracic NRD and may be more specific for leak localization.
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Affiliation(s)
- Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, USA
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Clifton Houk
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Shehanaz Ellika
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, USA
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16
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Hosur B, Jain NK, Sahdev R. Somnolence Due to Spontaneous Intracranial Hypotension. Neurol India 2023; 71:1324-1325. [PMID: 38174503 DOI: 10.4103/0028-3886.391367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Bharat Hosur
- Department of Radiodiagnosis, Armed Forces Medical College, Pune, Maharashtra, India
| | - Narendra Kumar Jain
- Department of Radiodiagnosis, Command Hospital, Lucknow, Uttar Pradesh, India
| | - Ravinder Sahdev
- Department of Radiodiagnosis, Armed Forces Medical College, Pune, Maharashtra, India
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Lützen N, Barvulsky Aleman E, Fung C, Beck J, Urbach H. Prone Dynamic CT Myelography in Spontaneous Intracranial Hypotension : Diagnostic Need and Radiation Doses. Clin Neuroradiol 2023; 33:739-745. [PMID: 36867243 PMCID: PMC10449968 DOI: 10.1007/s00062-023-01269-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/25/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND AND PURPOSE The diagnostic work-up in patients with spontaneous intracranial hypotension (SIH) and spinal longitudinal extradural CSF collection (SLEC) on magnetic resonance imaging (MRI) comprises dynamic digital subtraction myelography (dDSM) in prone position for leak detection. Dynamic computed tomography (CT) myelography (dCT-M) in prone position follows if the leak is not unequivocally located. A drawback of dCT‑M is a high radiation dose. This study evaluates the diagnostic needs of dCT-M examinations and measures to reduce radiation doses. METHODS Frequency, leak sites, length and number of spiral acquisitions, DLP and effective doses of dCT‑M were retrospectively recorded in patients with ventral dural tears. RESULTS Of 42 patients with ventral dural tears, 8 underwent 11 dCT‑M when the leak was not unequivocally shown on digital subtraction myelography. The median number of spiral acquisitions was 4 (range 3-7) and the mean effective radiation dose 30.6 mSv (range 13.1-62.16 mSv) mSv. Five of eight leaks were located in the upper thoracic spine (range C7/Th1-Th2/3). Bolus tracking of intrathecal contrast agent in dCT‑M was used to limit the number and length of spiral acquisitions. DISCUSSION A dCT‑M in prone position to localize a ventral dural tear is needed in every fifth patient with a SLEC on MRI. It is typically needed when the leak is located in the upper thoracic spine and when patients have broad shoulders. Measures to reduce the radiation dose include bolus tracking or to repeat the DSM with adjusted positioning of patient.
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Affiliation(s)
- Niklas Lützen
- Dept. of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Enrique Barvulsky Aleman
- Dept. of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Christian Fung
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juergen Beck
- Dept. of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Dept. of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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18
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Volz F, Fung C, Wolf K, Lützen N, Urbach H, Kraus LM, Omer M, Beck J, El Rahal A. Recovery and long-term outcome after neurosurgical closure of spinal CSF leaks in patients with spontaneous intracranial hypotension. Cephalalgia 2023; 43:3331024231196808. [PMID: 37652456 DOI: 10.1177/03331024231195830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid leak causes orthostatic headaches and impacts quality of life. Successful closure rates are often reported, whereas data on long-term outcome are still scarce. METHODS Between April 2020 and December 2022 surgically treated patients completed the Headache Impact Test-6 prior to surgery and at 14 days, three months, six months, and 12 months postoperatively. In addition to the Headache Impact Test-6 score, we extracted data related to orthostatic symptoms. RESULTS Eighty patients were included. Median Headache Impact Test-6 score preoperatively was 65 (IQR 61-69), indicating severe and disabling impact of headaches. At three months headache impact significantly improved to 49 (IQR 44-58) (p < 0.001) and remained stable up to 12 months (48, IQR 40-56), indicating little to no impact of headaches on quality of life. The need to lie down "always" or "very often" was reduced from 79% to 23% three months postoperatively (p < 0.001). CONCLUSIONS Surgical closure of spinal CSF leaks significantly improves the impact of headaches in the long term. At least three months should be expected for recovery. Despite permanent closure of the CSF-leak, a quarter of patients still have relevant long-term impairment, indicating the need for further research on its cause and possible treatment.
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Affiliation(s)
- Florian Volz
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Luisa Mona Kraus
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Mazin Omer
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Rizzo SA, Flanagan EP, Trejo-Lopez JA, Toledano M, Chia NH. Clinical Reasoning: New-Onset Diplopia and Headache in a Patient With Metastatic Breast Cancer. Neurology 2023; 100:927-931. [PMID: 36805434 PMCID: PMC10186217 DOI: 10.1212/wnl.0000000000206856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 12/07/2022] [Indexed: 02/22/2023] Open
Affiliation(s)
- Skylar A Rizzo
- From the Mayo Clinic Medical Scientist Training Program (S.A.R.); Department of Neurology (E.P.F., M.T., N.H.C.) and Department of Laboratory Medicine and Pathology (E.P.F., J.A.T.-L.), Mayo Clinic, Rochester, MN
| | - Eoin P Flanagan
- From the Mayo Clinic Medical Scientist Training Program (S.A.R.); Department of Neurology (E.P.F., M.T., N.H.C.) and Department of Laboratory Medicine and Pathology (E.P.F., J.A.T.-L.), Mayo Clinic, Rochester, MN
| | - Jorge A Trejo-Lopez
- From the Mayo Clinic Medical Scientist Training Program (S.A.R.); Department of Neurology (E.P.F., M.T., N.H.C.) and Department of Laboratory Medicine and Pathology (E.P.F., J.A.T.-L.), Mayo Clinic, Rochester, MN
| | - Michel Toledano
- From the Mayo Clinic Medical Scientist Training Program (S.A.R.); Department of Neurology (E.P.F., M.T., N.H.C.) and Department of Laboratory Medicine and Pathology (E.P.F., J.A.T.-L.), Mayo Clinic, Rochester, MN.
| | - Nicholas H Chia
- From the Mayo Clinic Medical Scientist Training Program (S.A.R.); Department of Neurology (E.P.F., M.T., N.H.C.) and Department of Laboratory Medicine and Pathology (E.P.F., J.A.T.-L.), Mayo Clinic, Rochester, MN
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20
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Bin Wan Hassan WMN, Mistretta F, Molinaro S, Russo R, Bosco G, Gambino A, Bergui M. Overview of Spontaneous Intracranial Hypotension and Differential Diagnosis with Chiari I Malformation. J Clin Med 2023; 12:jcm12093287. [PMID: 37176727 PMCID: PMC10179697 DOI: 10.3390/jcm12093287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.
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Affiliation(s)
| | - Francesco Mistretta
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Giovanni Bosco
- Department of Neuroscience, Stroke Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Andrea Gambino
- Department of Surgical Sciences, Radiology Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
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Pinto MJ, Braz L, Fonseca J, Pereira P, Trigo Barbosa P, Gomes A, Guimarães J. [Guidelines for the Diagnosis and Treatment of Spontaneous Intracranial Hypotension]. ACTA MEDICA PORT 2023; 36:363-367. [PMID: 37130571 DOI: 10.20344/amp.19432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/23/2023] [Indexed: 05/04/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is a syndrome characterized by disabling orthostatic headache, due to reduced cerebrospinal fluid (CSF) volume probably caused by a CSF fistula. It affects mostly women of working-age, although it is probably underdiagnosed. The aim of this article is to present a practical approach to the diagnosis and treatment of SIH. After a description of its symptoms and signs, we present a step-by-step approach to the confirmation of the diagnosis and treatment, considering different clinical scenarios. This is intended to guide clinical decision making, through a systematized and individualized management, aimed at the best interest of the patient.
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Affiliation(s)
- Maria João Pinto
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Luís Braz
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - José Fonseca
- Serviço de Neurorradiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Paulo Pereira
- Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto; Serviço de Neurocirurgia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Paula Trigo Barbosa
- Unidade de Dor Crónica. Serviço de Anestesiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Armanda Gomes
- Unidade de Dor Crónica. Serviço de Anestesiologia. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Joana Guimarães
- Serviço de Neurologia. Centro Hospitalar Universitário de São João. Porto; Departamento de Neurociências Clínicas e Saúde Mental. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
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Häni L, El Rahal A, Fung C, Volz F, Kraus LM, Lützen N, Urbach H, Schnell O, Beck J. Intraoperative Visualization of Flow in Direct Cerebrospinal Fluid-Venous Fistulas Using Intrathecal Fluorescein. Oper Neurosurg (Hagerstown) 2023; 24:e336-e341. [PMID: 37068025 DOI: 10.1227/ons.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/21/2022] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid-venous fistulas (CVFs) are a rare cause of spontaneous intracranial hypotension. Intraoperatively, CVFs are not readily identifiable and difficult to differentiate from normal veins. OBJECTIVE To assess the utility of intrathecal fluorescein injection intraoperatively to visualize and identify the CVF. METHODS We report a case series of patients treated surgically for a CVF. After surgical exposure, we injected intrathecal fluorescein (5-10 mg) through a lumbar catheter, which we placed immediately before surgery. RESULTS Four patients with spontaneous intracranial hypotension with a suspected CVF underwent surgical ligation with adjunctive intrathecal fluorescein application. Intraoperative fluorescein injection confirmed the presence of a CVF in 3 cases. In 2 cases, we observed rapid fluorescein filling of a single epidural vein constituting the CVF. Other epidural vessels did not fill with fluorescein. In 1 case, fluorescein helped to identify a residual CVF after previous incomplete embolization. In the fourth case, no CVF was found intraoperatively. By contrast, a meningeal nerve root diverticulum was visualized, wrapped, and clipped. CONCLUSION We demonstrate for the first time the direct intraoperative visualization of CVF using intrathecal fluorescein. CVF can be identified intraoperatively using fluorescein dye, which can be a valuable adjunct for the surgeon confronted with this disease.
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Affiliation(s)
- Levin Häni
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Luisa Mona Kraus
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
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23
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Lützen N, Zeitlberger A, Beck J, Urbach H. Teaching Neuroimages: Dynamic Digital Subtraction Myelography Discloses a Ventral CSF Leak in a Patient with Upper Limb Amyotrophy. Clin Neuroradiol 2023; 33:245-246. [PMID: 36063168 PMCID: PMC10014673 DOI: 10.1007/s00062-022-01210-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/07/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Niklas Lützen
- Dept. of Neuroradiology, Medical Center. University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Anna Zeitlberger
- Dept. of Neurosurgery, Medical Center. University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Dept. of Neurosurgery, Medical Center. University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Dept. of Neuroradiology, Medical Center. University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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24
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Evangelou P, Omrane MA, Thurow J, Mix M, Fung C, Lützen N, Blazhenets G, Urbach H, Beck J, Meyer PT. 68Ga-DOTA PET for Diagnosis of Spinal Cerebrospinal Fluid Leaks. J Nucl Med 2023; 64:430-436. [PMID: 35981896 DOI: 10.2967/jnumed.122.264059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/13/2022] [Accepted: 08/13/2022] [Indexed: 11/16/2022] Open
Abstract
Spontaneous intracranial hypotension due to spinal cerebrospinal fluid (CSF) leakage causes substantial disease burden. In many patients, the course is protracted and refractory to conservative treatment, requiring targeted therapy. We propose PET of the CSF space with 68Ga-DOTA as a state-of-the-art approach to radionuclide cisternography (RC) and validate its diagnostic value. Methods: This study is a retrospective analysis of patients with suspected intracranial hypotension due to spinal CSF leaks and who underwent whole-body PET/CT at 1, 3, and 5 h after intrathecal lumbar injection of 68Ga-DOTA. Two independent raters unaware of the clinical data analyzed all scans for direct and indirect RC signs of CSF leakage. Volume-of-interest analysis was performed to assess the biologic half-life of the tracer in the CSF space and the ratio of decay-corrected activity in the CSF space at 5 and 3 h (simplified marker of tracer clearance). Comprehensive stepwise neuroradiologic work-up served as a reference; additional validation was provided by surgical findings and follow-up. Results: Of 40 consecutive patients, 39 patients with a working diagnosis of intracranial hypotension due to a spinal CSF leak (spontaneous, n = 31; postintervention, n = 8) could be analyzed. A spinal CSF leak was verified by the neuroradiologic reference method in 18 of 39 patients. As the only direct and indirect diagnostic signs, extrathecal tracer accumulation at the cervicothoracic junction (67% sensitivity and 90% specificity) and lack of activity over the cerebral convexities (5 h; 94% sensitivity and 67% specificity) revealed a high diagnostic value for spinal CSF leaks. Their combination provided little improvement (71% sensitivity and 95% specificity). Additional quantitative analyses yielded no benefit (94% sensitivity and 53% specificity for biological half-life; 94% sensitivity and 58% specificity for the ratio of total radioactivity within the CSF space at 5 and 3 h). The location of direct signs (extrathecal tracer accumulation) did not correlate with verified sites of spinal CSF leakage. Conclusion: We propose CSF PET with 68Ga-DOTA as a novel, fast, and convenient approach to RC for verification but not localization of spinal CSF leaks with high sensitivity and specificity. CSF PET may fulfill an important gatekeeper function for stratifying patients toward escalation (ruling in) or deescalation (ruling out) of diagnostic and therapeutic measures. Further prospective studies are needed to validate the present results and determine the potential of the methods to reduce the burden to patients.
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Affiliation(s)
- Petros Evangelou
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mohamed Aymen Omrane
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Johannes Thurow
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Michael Mix
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Christian Fung
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ganna Blazhenets
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp T Meyer
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and
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25
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Wolf K, Luetzen N, Mast H, Kremers N, Reisert M, Beltrán S, Fung C, Beck J, Urbach H. CSF Flow and Spinal Cord Motion in Patients With Spontaneous Intracranial Hypotension: A Phase Contrast MRI Study. Neurology 2023; 100:e651-e660. [PMID: 36357188 PMCID: PMC9969913 DOI: 10.1212/wnl.0000000000201527] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Spontaneous intracranial hypotension (SIH) is characterized by loss of CSF volume. We hypothesize that in this situation of low volume, a larger CSF flow and spinal cord motion at the upper spine can be measured by noninvasive phase contrast MRI. METHODS A prospective, age-, sex-, and body mass index (BMI)-matched controlled cohort study on patients with SIH presenting with spinal longitudinal extradural fluid collection (SLEC) was conducted from October 2021 to February 2022. Cardiac-gated 2D phase contrast MRI sequences were acquired at segment C2/C3, and C5/C6 for CSF flow, and spinal cord motion analysis. Data processing was fully automated. CSF flow and spinal cord motion were analyzed by peak-to-peak amplitude and total displacement per segment and heartbeat, respectively. Clinical data included age, height, BMI, duration of symptoms, Bern score according to Dobrocky et al., and type of the spinal CSF leak according to Schievink et al. Groups were compared via the Mann-Whitney U test; multiple linear regression analysis was performed to address possible relations. RESULTS Twenty patients with SIH and 40 healthy controls were analyzed; each group consisted of 70% women. Eleven patients with SIH presented with type 1 leak, 8 with type 2, and 1 was indeterminate. CSF flow per heartbeat was increased at C2/C3 (peak-to-peak amplitude 65.68 ± 18.3 vs 42.50 ± 9.8 mm/s, total displacement 14.32 ± 3.5 vs 9.75 ± 2.7 mm, p < 0.001, respectively). Craniocaudal spinal cord motion per heartbeat was larger at segment C2/C3 (peak-to-peak amplitude 7.30 ± 2.4 vs 5.82 ± 2.0 mm/s, total displacement 1.01 ± 0.4 vs 0.74 ± 0.4 mm, p = 0.006, respectively) and at segment C5/C6 (total displacement 1.41 ± 0.7 vs 0.97 ± 0.4 mm, p = 0.021). DISCUSSION SLEC-positive patients with SIH show higher CSF flow and higher spinal cord motion at the upper cervical spine. This increased craniocaudal motion of the spinal cord per heartbeat might produce increased mechanical strain on neural tissue and adherent structures, which may be a mechanism leading to cranial nerve dysfunction, neck pain, and stiffness in SIH. Noninvasive phase contrast MRI of CSF flow and spinal cord motion is a promising diagnostic tool in SIH. TRIAL REGISTRATION INFORMATION German Clinical Trials Register, identification number: DRKS00017351. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that noninvasive phase contrast MRI of the upper spine identifies differences in CSF flow and spinal cord motion in patients with SIH compared with healthy controls.
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Affiliation(s)
- Katharina Wolf
- From the Departments of Neurology and Neurophysiology (K.W., S.B.), Neuroradiology (N.L., H.M., N.K., H.U.), Radiology, Medical Physics (M.R.), and Neurosurgery (C.F., J.B.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
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26
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Onuma K, Yanaka K, Nakamura K, Takahashi N, Tajima K, Watanabe D, Ishikawa E. Continuous Epidural Saline Infusion for the Treatment of Spontaneous Intracranial Hypotension. World Neurosurg 2023; 172:e640-e645. [PMID: 36739897 DOI: 10.1016/j.wneu.2023.01.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Spontaneous intracranial hypotension (SIH) is an increasingly recognized cause of orthostatic headache, but treatment strategies remain controversial. The epidural blood patch is a well-known and widely used treatment in patients with conservative treatment-resistant SIH, but symptoms may not improve even after multiple epidural blood patches, and resistant patients suffer from a lack of appropriate treatment options. Therefore, this study assessed the safety and efficacy of continuous epidural saline infusion (CESI) for SIH treatment. METHODS CESI was performed in 11 consecutive patients affected by conservative treatment-resistant SIH. Patient characteristics were obtained by reviewing medical records retrospectively. Headache intensity was assessed using the numerical rating scale (NRS), and changes in NRS before and after treatment were recorded. RESULTS The average treatment period for CESI was 21.3 ± 9.6 days, and the average follow-up period was 35.0 ± 30.2 months. CESI was without major complications or mortality, and no infections occurred, even without prophylactic antibiotics. The median NRS score before treatment was 10 points, improving to 5 points 1 day after infusion (P < 0.05), 2 points 1 week after infusion (P < 0.05), and 0 points at 3 months after infusion and the final follow-up. No patients have since experienced recurrence of orthostatic headaches. CONCLUSIONS CESI appears to be a safe and well-tolerated procedure for SIH. Further experience may demonstrate this technique to be a viable treatment option for SIH.
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Affiliation(s)
- Kuniyuki Onuma
- Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Kiyoyuki Yanaka
- Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Kazuhiro Nakamura
- Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Nobuyuki Takahashi
- Department of Radiology, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Keiichi Tajima
- Department of Anesthesiology, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan
| | - Daisuke Watanabe
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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27
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Halmagyi GM, Parker GD, Chen L, Welgampola MS, Watson JDG, Barnett MH, Todd MJ, El-Wahsh S, Rose V, Stoodley MA, Brennan JW. Progressive loss of hearing and balance in superficial siderosis due to occult spinal dural defects. Eur Arch Otorhinolaryngol 2023; 280:633-641. [PMID: 35841407 PMCID: PMC9849153 DOI: 10.1007/s00405-022-07523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/20/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Superficial siderosis, a progressive, debilitating, neurological disease, often presents with bilateral impairment of auditory and vestibular function. We highlight that superficial siderosis is often due to a repairable spinal dural defect of the type that can also cause spontaneous intracranial hypotension. METHODS Retrospective chart review of five patients presenting with moderate to severe, progressive bilateral sensorineural hearing loss as well as vestibular loss. All patients had developed superficial siderosis from spinal dural defects: three after trauma, one after spinal surgery and one from a thoracic discogenic microspur. RESULTS The diagnosis was made late in all five patients; despite surgical repair in four, hearing and vestibular loss failed to improve. CONCLUSIONS In patients presenting with progressive bilateral sensorineural hearing loss, superficial siderosis should be considered as a possible cause. If these patients also have bilateral vestibular loss, cerebellar impairment and anosmia, then the diagnosis is likely and the inevitable disease progress might be halted by finding and repairing the spinal dural defect.
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Affiliation(s)
- G Michael Halmagyi
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia. .,Central Clinical School, University of Sydney, Sydney, Australia.
| | - Geoffrey D Parker
- Radiology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Luke Chen
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Miriam S Welgampola
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia
| | - John D G Watson
- Neurology Department, Sydney Adventist Hospital, Sydney, Australia
| | - Michael H Barnett
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.,Brain Mind Centre, University of Sydney, Sydney, Australia
| | - Michael J Todd
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Shadi El-Wahsh
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Victoria Rose
- Audiology Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Marcus A Stoodley
- Neurosurgery Department, Macquarie University Hospital, Sydney, Australia
| | - Jeffrey W Brennan
- Neurosurgery Department, Royal Prince Alfred Hospital, Sydney, Australia
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28
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Farnsworth PJ, Madhavan AA, Verdoorn JT, Shlapak DP, Johnson DR, Cutsforth-Gregory JK, Brinjikji W, Lehman VT. Spontaneous intracranial hypotension: updates from diagnosis to treatment. Neuroradiology 2023; 65:233-243. [PMID: 36336758 DOI: 10.1007/s00234-022-03079-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks, which result in continued loss of CSF volume and multiple debilitating clinical manifestations. The estimated annual incidence of SIH is 5/100,000. Diagnostic methods have evolved in recent years due to improved understanding of pathophysiology and implementation of advanced myelographic techniques. Here, we synthesize recent updates and contextualize them in an algorithm for diagnosis and treatment of SIH, highlighting basic principles and points of practice variability or continued debate. This discussion includes finer points of SIH diagnosis, CSF leak classification systems, less common types and variants of CSF leaks, brain MRI Bern scoring, potential SIH complications, key technical considerations, and positioning strategies for different types of dynamic myelography. The roles of conservative measures, non-targeted or targeted blood patches, surgery, and recently developed endovascular techniques are presented.
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Affiliation(s)
- Paul J Farnsworth
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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29
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Signorelli F, Visocchi M. Spontaneous Intracranial Hypotension: Controversies in Treatment. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:209-211. [PMID: 38153471 DOI: 10.1007/978-3-031-36084-8_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is a disorder of low cerebrospinal fluid (CSF) volume secondary to CSF leakage through a dural defect along the neuraxis with an estimated incidence of 5 people per 100,000.Great debate persists on the optimal treatment of this pathology, and clinical results are often contradictory. SIH may be initially approached via conservative measures, such as bed rest that is often supplemented with hydration, caffeine, and theophylline, which overall relieve symptoms in a small subset of patients at 6 months. Epidural blood patching (EBP) is generally the next consideration in symptom management. It is the most commonly performed intervention for spinal CSF leaks, as the first option or following the failure of conservative treatment. Further procedures may be performed in the case of EBP partial or temporary response and if the spinal CSF leak has been definitively localized (Beck et al., Neurology 87:1220-26, 2016). In those cases, if the CSF leak is well localized, the surgical closure of the spinal CSF leak may be considered.SIH is a complex but treatable CSF disorder. Despite recent advances in the field of neuroimaging and the different therapeutic options available, the appropriate management remains controversial and should be tailored to the patient.
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Affiliation(s)
- Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
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30
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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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31
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Imaging, Clinical, and Demographic Differences in Patients With Type III Spinal Cerebrospinal Fluid Leak (Cerebrospinal Venous Fistulas) Compared With Patients With Types I and II Spinal Cerebrospinal Fluid Leak. J Comput Assist Tomogr 2022; 46:986-990. [PMID: 36112050 DOI: 10.1097/rct.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Spinal cerebrospinal fluid (CSF) leaks are an underdiagnosed cause of neurologic symptoms. The most common types of spinal CSF leaks are from dural tears (type I) and meningeal diverticula (type II). Cerebrospinal fluid-venous fistulas (type III) are less common and underrecognized. The purpose of this study was to evaluate the intracranial and spinal imaging findings in patients with types I/II versus type III leaks. MATERIALS AND METHODS This was a retrospective, institutional review board-approved study performed on adult patients between January 2020 to September 2021 with surgically confirmed type I/II/III spinal CSF leak. Patients had preoperative brain magnetic resonance imaging (MRI) with contrast and medical records detailing symptoms and clinical diagnoses. Patients were excluded for nondiagnostic brain MRIs. Demographic and clinical information were recorded. The presence of extra-axial collections, pachymeningeal thickening, brain sagging, and decreased pontomamillary distance were evaluated on MRI. RESULTS Seven patients had type III leaks, and 16 had type I/II leaks. Patients with type III leaks were older (P = 0.0003) and had higher rates of initial misdiagnosis (100% vs 31%) and longer times to correct diagnosis (P = 0.03) compared with type I/II leaks. Intracranial extra-axial collections were never seen with type III leaks but were seen in 50% of type I/II leaks. Pachymeningeal thickening and brainstem sagging occurred in nearly equal frequency between groups. Smaller pontomamillary distances were seen in type III leaks versus type I/II leaks (P = 0.047). CONCLUSIONS When evaluating patients with suspected spinal CSF leak, findings of older age, absence of intracranial extra-axial collections, and small pontomamillary distances may raise suspicion for type III versus type I/II leak.
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32
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Bergui M, Mistretta F, Bosco G, Cester G, Chioffi F, Gambino A, Molinaro S, Russo R, Sorarù G, Causin F. CSF-venous leak responsible for spontaneous intracranial hypotension treated by endovascular venous route: First cases in Italy. Interv Neuroradiol 2022:15910199221116011. [PMID: 35861992 DOI: 10.1177/15910199221116011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is due to a leakage of CSF lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. Clinical and MRI are usually typical enough to allow diagnosis, while finding the location of the dural breach is challenging. Since some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic path has been proposed. Here we report the first two successfully treated patients in Italy. Both had chronic and non specific symptoms, with severe reduction of quality of life; clinical symptoms improved after endovascular occlusion of the responsible vein.
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Affiliation(s)
- Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Francesco Mistretta
- Department of Surgical Sciences, Radiology Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giovanni Bosco
- Department of Neuroscience, Stroke Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giacomo Cester
- Neuroradiology Unit, University Hospital of Padova, Padua, Italy
| | - Franco Chioffi
- Neurosurgery Unit, University Hospital of Padova, Padua, Italy
| | - Andrea Gambino
- Department of Surgical Sciences, Radiology Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, 18691Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Gianni Sorarù
- Neurology Unit, Department of Neuroscience, 18624Azienda Ospedaliera di Padova, Padua, Italy
| | - Francesco Causin
- Neuroradiology Unit, University Hospital of Padova, Padua, Italy
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33
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Daripa B, Lucchese S. T2-Sampling Perfection With Application-Optimized Contrasts by Using Flip Angle Evolution (SPACE) Protocol MRI: A Safe, Minimally Invasive Screening Tool for Spinal CSF Leak Causing Spontaneous Intracranial Hypotension. Cureus 2022; 14:e26626. [PMID: 35949747 PMCID: PMC9357252 DOI: 10.7759/cureus.26626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 12/02/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) due to a spinal cerebrospinal fluid (CSF) leak is secondary cause of headache with potentially devastating consequences. Its diagnosis is complicated owing to the lack of a reasonable, minimally invasive screening test. This results in many patients remaining undiagnosed for years after the headache onset. Current testing approaches are either overly invasive, namely the CSF infusion protocol or both invasive and insensitive viz. lumbar puncture (LP) with an opening pressure (OP) or computed tomography myelogram (CTM). These diagnostic methods are frequently employed in a clinical setting since they require access to the thecal space; they unfortunately have a dearth of sensitivity. CTM will not document a leak if it is intermittent or very slow and in the setting of a spinal CSF leak, the OP on LP may be high, low, or normal. A potential remedy for this state is the T2-sampling perfection with application-optimized contrasts by using flip angle evolution (SPACE) protocol spinal magnetic resonance imaging (MRI). We present two cases that demonstrate its potential value as a screening tool. It is well known for its high sensitivity for identifying spinal pathology and is minimally invasive, making it a good choice for a screening modality when diagnosing possible SIH cases.
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Mamlouk MD, Shen PY, Jun P, Sedrak MF. Spontaneous Spinal CSF Leaks Stratified by Age, Body Mass Index, and Spinal Level. AJNR Am J Neuroradiol 2022; 43:1068-1072. [PMID: 35738670 DOI: 10.3174/ajnr.a7548] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/29/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There are 3 main types of spinal CSF leaks, and the imaging appearances are well-reported. Specific patient demographics and spinal locations of the various types of spinal leaks are less frequently described. The purpose of this article was to stratify the various types of spontaneous CSF leaks on the basis of age, body mass index, and spinal level. MATERIALS AND METHODS Retrospective review was performed for all patients with spontaneous spinal CSF leaks identified on CT myelography. Age, body mass index, and spinal CSF leak type and level were recorded. RESULTS Sixty-five patients (37 women and 28 men) had spinal CSF leaks. Type 1 CSF leaks (dural tears) were observed in 25 patients (mean age, 44.5 years; mean body mass index, 24.3) and were most common in the upper thoracic spine (72%), particularly at the T1-T2 level (36%). Type 2 CSF leaks (ruptured meningeal diverticula) were observed in 4 patients (mean age, 45.5 years; mean body mass index, 27.5) and were all seen in the lower thoracic spine. Type 3 CSF leaks (CSF-venous fistulas) were observed in 36 patients (mean age, 58.8 years; mean body mass index, 27.0) and were most common on the right side (72%) and in the lower thoracic spine (56%). CONCLUSIONS Type 1 CSF leaks occurred in younger patients with a normal body mass index, while patients with type 3 CSF leaks were relatively older and had an elevated body mass index. Type 1 leaks mostly occurred in the upper thoracic spine, and types 2 and 3 leaks mostly occurred in the lower thoracic spine.
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Affiliation(s)
- M D Mamlouk
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California .,Department of Radiology and Biomedical Imaging (M.D.M.), University of California, San Francisco, San Francisco, California
| | - P Y Shen
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - P Jun
- From the Department of Radiology (M.D.M., P.Y.S., P.J.), The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, Santa Clara, California
| | - M F Sedrak
- Department of Neurosurgery (M.F.S.), The Permanente Medical Group, Kaiser Permanente Medical Center, Redwood City, Redwood City, California
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Lützen N, Kremers N, Fung C, Beck J, Urbach H. The "hyperdense basivertebral vein" sign: another marker of a CSF-venous fistula. Neuroradiology 2022; 64:627-630. [PMID: 35106631 PMCID: PMC8850216 DOI: 10.1007/s00234-022-02908-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/22/2022] [Indexed: 11/26/2022]
Abstract
CSF-venous fistulas — initially described in 2014 — are a significant cause of spontaneous intracranial hypotension. Dynamic lateral decubitus digital subtraction and/or CT myelography typically show a hyperdense paraspinal vein. In case of a central drainage toward the internal vertebral venous plexus, it is the “hyperdense basivertebral vein” which should be searched for carefully.
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Affiliation(s)
- Niklas Lützen
- Dept. of Neuroradiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Nico Kremers
- Dept. of Neuroradiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Christian Fung
- Dept. of Neurosurgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Dept. of Neurosurgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Dept. of Neuroradiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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Chen HC, Chai JW, Wu CC, Chen PL, Teng CL. Magnetic resonance imaging predicted the therapeutic response of patients with spinal cerebrospinal fluid leakage undergoing targeted epidural blood patch. Br J Radiol 2022; 95:20210841. [PMID: 34762485 PMCID: PMC8722244 DOI: 10.1259/bjr.20210841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Most patients with spinal cerebrospinal fluid (CSF) leakage require an epidural blood patch (EBP); however, the response to treatment is varied. This study aimed to compare the MRI findings at follow-up between EBP effective and non-effective groups and to identify imaging findings that predict EBP treatment failure. METHODS We retrospectively reviewed 48 patients who received EBP treatment for spinal CSF leakage. These patients were stratified into two groups: EBP effective (n = 27) and EBP non-effective (n = 21) using the results of the 3 month MRI as the end point. RESULTS Compared to the EBP non-effective group, the patients in the EBP effective group had a lower spinal CSF leakage number (2.67 vs 12.48; p = 0.001), lower spinal epidural fluid accumulation levels (3.00 vs 7.48; p = 0.004), brain descend (11.11% vs 38.10%; p = 0.027), pituitary hyperemia (18.52% vs 57.14%; p = 0.007), and decreased likelihood of ≥three numbers of spinal CSF leakage (25.93% vs 90.48%; p = 0.001) in the post-EBP MRI. Clinical non-responsiveness (OR: 57.84; 95% CI: 3.47-972.54; p = 0.005) and ≥three numbers of spinal CSF leakage (OR: 15.13; 95% CI: 1.45-159.06; p = 0.023) were associated with EBP failure. Between these variables, ≥three numbers of spinal CSF leakage identified using the post-EBP MRI demonstrated greater sensitivity in predicting EBP failure compared to clinical non-responsiveness (90.48% vs 61.9%). CONCLUSION The number of spinal CSF leakage identified using the post-EBP MRI with a cut-off value of three is an effective predictor of EBP failure. ADVANCES IN KNOWLEDGE Compared to clinical responsiveness, the post-EBP MRI provided a more objective approach to predict the effectiveness of EBP treatment in patients with spinal CSF leakage.
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