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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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Alomari MH, Shahin MM, Fishman SJ, Kerr CL, Smith ER, Eng W, Ruiz-Gutierrez M, Adams DM, Orbach DB, Chaudry G, Shaikh R, Chewning R, Alomari AI. Cerebrospinal fluid leak in epidural venous malformations and blue rubber bleb nevus syndrome. J Neurosurg Spine 2022; 37:439-445. [PMID: 35364593 DOI: 10.3171/2022.1.spine2138] [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: 01/08/2021] [Accepted: 01/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical manifestations of blue rubber bleb nevus syndrome (BRBNS) and multifocal venous malformation (MVM) vary depending on the location of the lesions. The aim of this study was to assess the risk of developing CSF leaks in patients with epidural venous malformations (VMs). METHODS The authors retrospectively investigated the relationship between the development of a CSF leak and the presence of epidural VMs. RESULTS Nine patients (5 females) had epidural VMs and presentation that was confirmatory or suggestive of a CSF leak: 4 had BRBNS, 4 had MVMs, and 1 had a solitary VM. Of 66 patients with BRBNS, clinical and imaging features of CSF leak were noted in 3 (4.5%) with epidural VMs at the age of 11-44 years. A fourth patient had suggestive symptoms without imaging confirmation. An epidural blood patch was ineffective in 2 patients, both with more than one source of leakage, requiring surgical repair or decompression. Symptomatic downward displacement of the cerebellar tonsils was noted in 3 patients with MVM and 1 with a solitary VM; 3 required surgical decompression. CONCLUSIONS These findings suggest an increased risk of CSF leak in patients with epidural VM, including BRBNS, MVMs, and solitary VMs. Awareness of the association between epidural VM and CSF leakage may facilitate earlier diagnosis and therapeutic intervention.
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Affiliation(s)
| | | | | | - Cindy L Kerr
- 1Division of Vascular and Interventional Radiology
| | | | - Whitney Eng
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melisa Ruiz-Gutierrez
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Denise M Adams
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Raja Shaikh
- 1Division of Vascular and Interventional Radiology
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A systematic review and meta-analysis of factors affecting the outcome of the epidural blood patching in spontaneous intracranial hypotension. Neurosurg Rev 2021; 44:3079-3085. [PMID: 33611638 DOI: 10.1007/s10143-021-01505-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/20/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an often misdiagnosed condition resulting from non-iatrogenic cerebrospinal fluid (CSF) hypovolemia, typically secondary to spinal CSF leakage. Patients commonly present with posture-related headache, nausea, and vomiting. Following failure of conservative measures, epidural blood patching (EBP) is the most commonly performed intervention for spinal CSF leaks. The authors performed a systematic review and meta-analysis of existing literature to evaluate the role of different factors possibly affecting the efficacy of the EBP procedure. In accordance with the PRISMA guidelines, PubMed/Medline and SCOPUS databases were searched. Six eligible articles were retrieved. Five hundred patients were treated for SIH with EBP, of which 300 reported good response defined as complete remission of symptoms within 48 h after the first EBP requiring no further invasive treatment. Among the factors available for meta-analysis, none was found to be statistically significant in affecting the efficacy of the EBP procedure. A largely symmetrical funnel plot is reported for all the variables evaluated, indicating that publication bias did not play a significant role in the observed effects. The current knowledge about SIH and the EBP is scarce. The existing literature is contradictory and insufficient to aid in clinical practice. More studies are needed to draw significant conclusions that may help in the identification of patients at higher risk of EBP failure, who may benefit from different approaches.
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Paris D, Rousset D, Bonneville F, Fabre N, Faguer S, Huguet-Rigal F, Larcher C, Martin C, Osinski D, Gaussiat F, Delamarre L, Brauge D, Fourcade O, Geeraerts T, Mrozek S. Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report. Headache 2020; 60:2583-2588. [PMID: 32990351 DOI: 10.1111/head.13977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH. METHODS Case report. CASE DESCRIPTION We report here a case of comatose patient due to spontaneous IH complicated by CVT and subdural hemorrhage. The correct diagnosis was delayed due to many confounding factors. IH was suspected after subdural hemorrhage recurrence and confirmed by magnetic resonance imaging (MRI). After 2 epidural patches with colloid, favorable outcome was observed. DISCUSSION The most common presentation of IH is postural orthostatic headaches. In the present case report, the major clinical signs were worsening of consciousness and coma, which are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within the brain. CONCLUSION Association of CVT and subdural hemorrhage should lead to suspect IH. Brain imaging can help and find specific signs of IH.
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Affiliation(s)
- Diane Paris
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - David Rousset
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Fabrice Bonneville
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Nelly Fabre
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Stanislas Faguer
- Department of Nephrology, Dialysis and Multi-Organ Transplantation, Toulouse University Hospital, Toulouse, France
| | - Françoise Huguet-Rigal
- Department of Hematology, University Institute of Cancer of Toulouse-Oncopole, Toulouse, France
| | - Claire Larcher
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Charlotte Martin
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Diane Osinski
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - François Gaussiat
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Louis Delamarre
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - David Brauge
- Department of Neurosurgery, University Hospital of Toulouse, Toulouse, France
| | - Olivier Fourcade
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Ségolène Mrozek
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
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Chondrogiorgi M, Zikou AK, Konitsiotis S, Markoula S. Postpartum intracranial hypotension complicated by posterior reversible encephalopathy syndrome: a case report. Int J Neurosci 2020; 130:1174-1177. [PMID: 32070168 DOI: 10.1080/00207454.2020.1730365] [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: 10/25/2022]
Abstract
Purpose: To present an unusual case of posterior encephalopathy syndrome (PRES) preceded by intracranial hypotension.Materials and Methods: We present a case of a 27-year-old parturient with an uneventful pregnancy that shortly after labor developed a persistent headache with characteristics compatible with intracranial hypotension. The patient had undergone epidural anesthesia for caesarian section. Results: The symptomatology of intracranial hypotension was attributed to inadvertent dural puncture during epidural anesthesia. The MRI revealed multiple white matter lesions located in frontal, temporal and parietal regions of both hemispheres. The type of lesions was suggestive of PRES. Pachymeningeal enhancement was also observed. The patient was managed conservatively. The symptoms improved gradually and the imaging findings resolved completely. Conclusions: This case demonstrates the need for clinical alertness for PRES in patients with prolonged and possibly atypical symptoms of intracranial hypotension. As probable causal relationship between these disorders we propose a sympathetic over-activation as a result of cerebrospinal fluid leakage leading to vasospasm and manifestation of PRES.
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Affiliation(s)
| | - Anastasia K Zikou
- Department of Radiology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Sofia Markoula
- Department of Neurology, University Hospital of Ioannina, Ioannina, Greece
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Yılmaz TF, Aralasmak A, Toprak H, Kocaman G, Alkan A. Pontine bleeding following drainage of subdural hematoma in craniospinal hypotension. Radiol Case Rep 2018; 13:228-232. [PMID: 29552262 PMCID: PMC5853140 DOI: 10.1016/j.radcr.2017.09.019] [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] [Received: 05/17/2017] [Revised: 07/29/2017] [Accepted: 09/25/2017] [Indexed: 11/30/2022] Open
Abstract
Craniospinal hypotension is the syndrome of orthostatic headache associated with low cerebrospinal fluid pressure. Imaging findings are usually explained by Monro-Kellie hypothesis stating that the craniospinal compartment is incompressible and any increase in volume of one of the craniospinal constituents (blood, cerebrospinal fluid, and parenchyma) must be compensated by a decrease in volume of another constituent or vice versa. We report a case of craniospinal hypotension in whom drainage of subdural hematoma upon clinical impairments resulted in pontine hemorrhage, supporting Monro-Kellie hypothesis.
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Affiliation(s)
- Temel Fatih Yılmaz
- Department of Radiology, Kars State Hospital, Yenişehir Mahallesi, İsmail Aytemiz Bulvarı, No:55, 36200 Kars, Turkey
| | - Ayse Aralasmak
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey, Adnan Menderes Bulvarı, Vatan Caddesi, 34093 Fatih/İstanbul, Turkey
| | - Huseyin Toprak
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey, Adnan Menderes Bulvarı, Vatan Caddesi, 34093 Fatih/İstanbul, Turkey
| | - Gulsen Kocaman
- Department of Neurology, Bezmialem Vakif University, Adnan Menderes Bulvarı, Vatan Caddesi, 34093 Fatih/İstanbul, Turkey
| | - Alpay Alkan
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey, Adnan Menderes Bulvarı, Vatan Caddesi, 34093 Fatih/İstanbul, Turkey
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Sergeev AV. [Migraine 'masks': differential diagnosis of acute headache]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:96-102. [PMID: 29460913 DOI: 10.17116/jnevro20181181196-102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Differential diagnosis of migraine, can be difficult, especially of migraine with aura. On the one hand, some diseases can produce symptoms similar to migraine (cerebral aneurysm before rupture, reversible cerebral vasoconstriction syndrome). On the other hand, migraine with aura and some other disorders are conditions that have common pathophysiological mechanisms (e.g., CADASIL and MELAS syndrome, antiphospholipid syndrome). Thirdly, clinical presentations of migraine are often difficult to distinguish from features of other headache conditions (migraine with aura - transient ischemic attack, migraine with visual aura - occipital epilepsy). The author discusses the differential diagnosis of acute headache, especially thunderclap headache, and main strategies of effective treatment of migraine attacks.
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Affiliation(s)
- A V Sergeev
- Sechenov First Moscow State Medical University, Moscow, Russia
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Tsai YH, Chen HC, Tung H, Wu YY, Chen HM, Pan KJ, Cheng DC, Chen JH, Chen CCC, Chai JW, Shen WC. Noninvasive assessment of intracranial elastance and pressure in spontaneous intracranial hypotension by MRI. J Magn Reson Imaging 2018; 48:1255-1263. [PMID: 29437266 DOI: 10.1002/jmri.25976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/24/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is often misdiagnosed, and can lead to severe complications. Conventional MR sequences show a limited ability to aid in this diagnosis. MR-based intracranial pressure (MR-ICP) may be able to detect changes of intracranial elastance and pressure. PURPOSE To determine whether MR-ICP is able to differentiate SIH patients from normal subjects, improve diagnostic sensitivity, and provide an insight into the pathophysiology. STUDY TYPE Prospective. SUBJECTS Twenty-eight SIH cases with orthostatic headache and 20 healthy volunteers. FIELD STRENGTH/SEQUENCE Cine phase-contrast MRI on a 1.5T scanner. ASSESSMENT Intracranial elastance (IE) was derived from the ratio of the peak-to-peak cerebrospinal fluid (CSF) pressure gradient (PGcsf-pp ) and intracranial volume change, obtained by summing all flows before each sequential cardiac frame. STATISTICAL TESTS Student's t-test was used to compare the MR-ICP indexes and flow parameters between SIH patients and healthy volunteers (P < 0.01). RESULTS The SIH patients with cervical epidural venous dilatation (EVD) had an IE of 0.121 ± 0.027 mmHg/cm/ml, significantly higher than that of the normal volunteers (0.085 ± 0.027 mmHg/cm/ml; P = 0.002). In contradistinction, the EVD-negative SIH patients, including four with no sign of CSF leaks, had significantly lower IE (0.055 ± 0.012 mmHg/cm/ml) compared with the normal volunteers and the EVD-positive group (P = 0.001, P < 0.001). The EVD-negative patients had significantly lower PGcsf-pp (0.024 ± 0.007 mmHg/cm) compared with the normal volunteers and the EVD-positive group (0.035 ± 0.011 mmHg/cm, 0.040 ± 0.010 mmHg/cm; P = 0.003, P < 0.001). Additionally, the MRI flow study showed a significant decrease in transcranial inflow and outflow of SIH patients (P < 0.01). DATA CONCLUSION We found that the MR-ICP method is potentially more sensitive than morphological MRI in the early diagnosis of SIH. Also, contrary to common belief, our results suggest that an abnormal craniospinal elastance might be the cause of SIH, instead of CSF leak. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1255-1263.
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Affiliation(s)
- Yi-Hsin Tsai
- Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Chieh Chen
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsin Tung
- Neurological Institute, Taichung Veterans General Hospital, Taiwan
| | - Yi-Ying Wu
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsian-Min Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Biomedical Engineering, Hung Kuang University, Taichung, Taiwan
| | - Kuan-Jung Pan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Da-Chuan Cheng
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
| | - Jeon-Hor Chen
- Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California, Irvine, California, USA.,Department of Radiological Technology, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Clayton Chi-Chang Chen
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Radiology, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
| | - Jyh-Wen Chai
- College of Medicine, China Medical University, Taichung, Taiwan.,Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wu-Chung Shen
- College of Medicine, China Medical University, Taichung, Taiwan.,Department of Radiology, China Medical University Hospital, Taichung, Taiwan
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Tsai PH, Fuh JL, Lirng JF, Wang SJ. Heavily T2-Weighted MR Myelography in Patients With Spontaneous Intracranial Hypotension: A Case—Control Study. Cephalalgia 2016; 27:929-34. [PMID: 17645756 DOI: 10.1111/j.1468-2982.2007.01376.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We performed whole-spine heavily T2-weighted magnetic resonance (MR) myelography using a single-shot fast spin-echo pulse sequence in 17 patients (8 M/9 F) with spontaneous intracranial hypotension (SIH) to detect abnormal cerebrospinal fluid (CSF) collections. In addition, a group of age- and sex-matched controls were recruited. Follow-up MR myelography was also done at 3 weeks. MR myelography showed three kinds of abnormal CSF collections in 15 patients with SIH (88%): epidural fluid collection ( n = 15, 88%), C1-2 extraspinal collections ( n = 6, 35%) and CSF collections along nerve roots in the lower cervical or upper thoracic spines ( n = 6, 35%). One patient (6%) showed a meningeal diverticulum. In contrast, none of the controls showed these findings. Overall, MR myelography results helped in early diagnosis of SIH in four (24%) patients whose initial brain MRIs failed to show typical SIH findings. Follow-up MR myelography results were compatible with the clinical changes with κ statistics of 0.52 and an agreement rate of 76%. Our study showed heavily T2-weighted MR myelography provided a rapid, non-invasive and high yield method to diagnose and follow-up patients with SIH. Whether the CSF collections along the nerve roots represent the ongoing leakage sites warrants further study.
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Affiliation(s)
- P-H Tsai
- Neurological Department, Suao Veterans Hospital, Yi-Lan, Taiwan
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10
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Kim WJ, Shin HY, Kim YC, Moon JY. Clinical Association Between Brain MRI Findings With Epidural Blood Patch in Spontaneous Intracranial Hypotension. J Neurosurg Anesthesiol 2016; 28:147-52. [DOI: 10.1097/ana.0000000000000259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Dural Thickening of the Internal Auditory Canal in Patients With Spontaneous Intracranial Hypotension Syndrome. J Comput Assist Tomogr 2015; 40:297-300. [PMID: 26571060 DOI: 10.1097/rct.0000000000000342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to assess the utility of dural thickening of the internal auditory canal (IAC) in patients with spontaneous intracranial hypotension (SIH) syndrome and determined the sensitivity and specificity of this image finding. METHODS Magnetic resonance images were evaluated for 22 cases of definite SIH and 16 cases of unlikely SIH. On contrast-enhanced magnetic resonance imaging, pachymeningeal enhancement and dural thickening of the IAC were assessed. RESULTS Pachymeningeal enhancement was observed in 21 of 22 patients in the definite SIH group and 1 of 16 patients in the unlikely SIH group (sensitivity, 95.5%; specificity, 93.8%). Dural thickening of the IAC was observed in 15 of 22 patients in the definite SIH group and 0 of 16 patients in the unlikely SIH group (sensitivity, 68.2%; specificity, 100%). CONCLUSIONS Dural thickening of the IAC showed 100% specificity for SIH syndrome and can increase the accuracy of diagnosis of SIH syndrome.
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12
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Harreld JH, Mohammed N, Goldsberry G, Li X, Li Y, Boop F, Patay Z. Postoperative intraspinal subdural collections after pediatric posterior fossa tumor resection: incidence, imaging, and clinical features. AJNR Am J Neuroradiol 2015; 36:993-9. [PMID: 25614472 DOI: 10.3174/ajnr.a4221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/01/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postoperative intraspinal subdural collections in children after posterior fossa tumor resection may temporarily hinder metastasis detection by MR imaging or CSF analysis, potentially impacting therapy. We investigated the incidence, imaging and clinical features, predisposing factors, and time course of these collections after posterior fossa tumor resection. MATERIALS AND METHODS Retrospective review of postoperative spine MRI in 243 children (5.5 ± 4.6 years of age) from our clinical data base postresection of posterior fossa tumors from October 1994 to August 2010 yielded 37 (6.0 ± 4.8 years of age) subjects positive for postoperative intraspinal subdural collections. Their extent and signal properties were recorded for postoperative (37/37), preoperative (15/37), and follow-up spine (35/37) MRI. Risk factors were compared with age-matched internal controls (n = 37, 5.9 ± 4.5 years of age). Associations of histology, hydrocephalus and cerebellar tonsillar herniation, and postoperative intracranial subdural collections with postoperative intraspinal subdural collections were assessed by the Fisher exact test or χ(2) test. The association between preoperative tumor volume and postoperative intraspinal subdural collections was assessed by the Wilcoxon rank sum test. RESULTS The overall incidence of postoperative intraspinal subdural collections was 37/243 (15.2%), greatest ≤7 days postoperatively (36%); 97% were seen 0-41 days postoperatively (12.9 ± 11.0 days). They were T2 hyperintense and isointense to CSF on T1WI, homogeneously enhanced, and resolved on follow-up MR imaging (35/35). None were symptomatic. They were associated with intracranial subdural collections (P = .0011) and preoperative tonsillar herniation (P = .0228). CONCLUSIONS Postoperative intraspinal subdural collections are infrequent and clinically silent, resolve spontaneously, and have a distinctive appearance. Preoperative tonsillar herniation appears to be a predisposing factor. In this series, repeat MR imaging by 4 weeks documented improvement or resolution of these collections in 88%.
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Affiliation(s)
- J H Harreld
- From the Departments of Radiological Sciences (J.H.H., Z.P.)
| | - N Mohammed
- Department of Imaging Diagnostic (N.M.), Institute of Paediatric, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - G Goldsberry
- Department of Radiology (G.G.), McFarland Clinic, Ames, Iowa
| | - X Li
- Biostatistics (X.L., Y.L.)
| | - Y Li
- Biostatistics (X.L., Y.L.)
| | - F Boop
- Surgery (F.B.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Z Patay
- From the Departments of Radiological Sciences (J.H.H., Z.P.)
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13
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Abstract
A literature search found no clinical trials or guidelines addressing the management of spontaneous intracranial hypotension (SIH). Based on the available literature and expert opinion, we have developed recommendations for the diagnosis and management of SIH. For typical cases, we recommend brain magnetic resonance (MR) imaging with gadolinium to confirm the diagnosis, and conservative measures for up to two weeks. If the patient remains symptomatic, up to three non-directed lumbar epidural blood patches (EBPs) should be considered. If these are unsuccessful, non-invasive MR myelography, radionuclide cisternography, MR myelography with intrathecal gadolinium, or computed tomography with myelography should be used to localize the leak. If the leak is localized, directed EPBs should be considered, followed by fibrin sealant or neurosurgery if necessary. Clinically atypical cases with normal brain MR imaging should be investigated to localize the leak. Directed EBPs can be used if the leak is localized; non-directed EBPs should be used only if there are indirect signs of SIH.
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14
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Griauzde J, Gemmete JJ, Chaudhary N, Wilson TJ, Pandey AS. Large-volume blood patch to multiple sites in the epidural space through a single-catheter access site for treatment of spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2014; 35:1841-6. [PMID: 24788127 DOI: 10.3174/ajnr.a3945] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension can be a therapeutic challenge to the treating physician. In this study, we present our experience with the administration of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site. MATERIALS AND METHODS A retrospective review was conducted of patients with spontaneous intracranial hypotension who underwent a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site from 2010 to 2012. Patient demographic data, clinical charts, indications for treatment, radiographic images, procedure notes, and postprocedure hospital course were reviewed. RESULTS Overall, 9 patients were identified who underwent 20 blood patch procedures. Patients were selected to undergo the large-volume procedure either because they had a failed site-directed epidural blood patch or if imaging demonstrated multiple possible leak sites. There were 6 women and 3 men, with an average age of 33.5 years. The mean volume of blood injected per procedure was 54.1 mL (median=55 mL; range=38-70 mL). All patients had an orthostatic headache as one of their presenting symptoms; 22% also presented with neurocognitive decline and behavioral changes; 89% of patients had improvement or resolution of their symptoms; and 80% of patients who had a previously failed site-directed epidural blood or fibrin glue patch improved with a large volume catheter-directed blood patch. CONCLUSIONS Our experience supports the use of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site for the treatment of spontaneous intracranial hypotension. Additionally, our results indicate a role for this procedure in refractory cases of spontaneous intracranial hypotension.
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Affiliation(s)
- J Griauzde
- From the Departments of Radiology (J.G., J.J.G., N.C.)
| | - J J Gemmete
- From the Departments of Radiology (J.G., J.J.G., N.C.) Neurosurgery (J.J.G., N.C., T.J.W., A.S.P.) Otolaryngology (J.J.G.), University of Michigan Hospitals, Ann Arbor, Michigan.
| | - N Chaudhary
- From the Departments of Radiology (J.G., J.J.G., N.C.) Neurosurgery (J.J.G., N.C., T.J.W., A.S.P.)
| | - T J Wilson
- Neurosurgery (J.J.G., N.C., T.J.W., A.S.P.)
| | - A S Pandey
- Neurosurgery (J.J.G., N.C., T.J.W., A.S.P.)
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Chu E, McAuliffe W. Use of flat panel DynaCT myelography to locate the site of CSF leak. J Med Imaging Radiat Oncol 2014; 57:455-9. [PMID: 23870342 DOI: 10.1111/1754-9485.12072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 03/21/2013] [Indexed: 11/27/2022]
Abstract
Spontaneous intracranial hypotension is often treated conservatively or with epidural blood patch. Patients who are resistant to these treatments require accurate imaging localisation of the site of cerebrospinal fluid (CSF) leak for surgical repair. We describe two patients where MRI, CT myelography and MRI gadolinium myelography showed evidence of a large volume of epidural CSF, but failed to identify the pressure site of leak. Subsequently, DynaCT (Siemens, Erlangen, Germany) accurately identified the site with confidence in both cases, confirmed at surgery. This technique of using a flat panel detector-based, angiographic system to produce high quality, high-contrast multiplanar CT images for detecting the source of rapid CSF leak is detailed.
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Affiliation(s)
- Eric Chu
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Tung H, Liao YC, Wu CC, Chang MH, Chen CCC, Chen PL, Chen HC. Usefulness of phase-contrast magnetic resonance imaging for diagnosis and treatment evaluation in patients with SIH. Cephalalgia 2014; 34:584-93. [PMID: 24414094 DOI: 10.1177/0333102413519513] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/29/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Most diagnostic tools for spontaneous intracranial hypotension (SIH) are either invasive or occasionally inconsistent with the clinical condition. In this study, we examined the cerebrospinal fluid (CSF) dynamics in SIH using phase-contrast magnetic resonance (PC-MR) imaging. MATERIALS AND METHOD Seventeen SIH patients and 32 healthy individuals, matched by sex and age, were recruited. Each person underwent brain and PC-MR imaging using 3-Tesla MRI. We evaluated the differences in image parameters among patients during the initial and recovery stages against the status of the control group. RESULTS SIH patients had lower CSF flow-volume, flux, peak velocity, and higher systolic-to-diastolic time ratio, as well as systolic-to-diastolic volume ratio compared to the control group and the conditions when they recovered. The flow time and volume of the diastolic phase markedly increased after treatment. The discriminating power of PC-MR for SIH was good. Diffuse pachymeningeal enhancement and venous engorgement were present when their PC-MR values were lower than the cut-off values for SIH diagnosis. The headache scores correlated with the peak velocity and pituitary volume. CONCLUSION Noninvasive PC-MR could provide valid parameters for diagnosis and treatment follow-up in SIH patients. It may be more sensitive than conventional brain MRI.
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Affiliation(s)
- Hsin Tung
- Section of Neurology, Taichung Veterans General Hospital, Taiwan, ROC
| | - Yi-Chu Liao
- Section of Neurology, Taichung Veterans General Hospital, Taiwan, ROC Department of Neurology, National Yang-Ming University, School of Medicine, Taiwan, ROC
| | - Chih-Ceng Wu
- Department of Anesthesiology, Taichung Veterans General Hospital, Taiwan, ROC
| | - Ming-Hong Chang
- Section of Neurology, Taichung Veterans General Hospital, Taiwan, ROC Department of Neurology, National Yang-Ming University, School of Medicine, Taiwan, ROC
| | - Clayton Chi-Chang Chen
- Department of Radiology, Taichung Veterans General Hospital, Taiwan, ROC Department of Radiological Technology and Graduate Institute of Radiological Science, Central Taiwan University of Science and Technology, Taiwan, ROC Department of Physical Therapy, Hungkuang University of Technology, Taiwan, ROC Department of Physical Therapy and Assistive Technology, National Yang Ming University, Taiwan, ROC
| | - Po-Lin Chen
- Section of Neurology, Taichung Veterans General Hospital, Taiwan, ROC Department of Neurology, National Yang-Ming University, School of Medicine, Taiwan, ROC
| | - Hung-Chieh Chen
- Department of Radiology, Taichung Veterans General Hospital, Taiwan, ROC Department of Radiology, National Yang-Ming University School of Medicine, Taiwan, ROC
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Franzini A, Messina G, Chiapparini L, Bussone G. Treatment of spontaneous intracranial hypotension: evolution of the therapeutic and diagnostic modalities. Neurol Sci 2013; 34 Suppl 1:S151-5. [DOI: 10.1007/s10072-013-1364-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Schwedt TJ. Thunderclap Headaches: A Focus on Etiology and Diagnostic Evaluation. Headache 2013; 53:563-9. [DOI: 10.1111/head.12041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2012] [Indexed: 11/27/2022]
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19
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Sagging brain development after lumbar puncture agrees with Monro-Kellie hypothesis. J Neurol 2013; 260:920-2. [PMID: 23314405 DOI: 10.1007/s00415-012-6811-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 12/11/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022]
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20
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Intracranial hypotension syndrome: A post dural puncture headache? COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2012.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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22
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Lahoria R, Allport L, Glenn D, Masters L, Shnier R, Davies M, Hersch M. Spontaneous low pressure headache – A review and illustrative patient. J Clin Neurosci 2012; 19:1076-9. [DOI: 10.1016/j.jocn.2011.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 10/23/2011] [Accepted: 12/03/2011] [Indexed: 10/28/2022]
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23
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Spontaneous intracranial hypotension: case reports and literature review. Ir J Med Sci 2011; 181:171-7. [DOI: 10.1007/s11845-011-0766-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 09/23/2011] [Indexed: 01/09/2023]
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Watanabe K, Hashizume K, Kawaguchi M, Fujiwara A, Sasaoka N, Furuya H. Fluoroscopically guided epidural blood patch with subsequent spinal CT scans in the treatment of spontaneous cerebrospinal fluid hypovolemia. J Neurosurg 2011; 114:1731-5. [DOI: 10.3171/2011.1.jns101326] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Recent evidence has indicated that the efficacy of the epidural blood patch (EBP) in the treatment of spontaneous CSF hypovolemia (SCH) is still limited. Therefore, further improvement of the EBP technique is an important clinical challenge. The authors describe a series of cases of SCH treated with fluoroscopically guided placement of an EBP and followed up with subsequent spinal CT scans.
Methods
Thirteen patients with SCH that was proven on CT myelography studies underwent epidural puncture under fluoroscopic guidance and received an injection of a mixture of contrast medium and autologous blood. Contrast medium was injected to cover the area of CSF leakage during EBP guided by fluoroscopy, and the spread of the blood was subsequently evaluated using spinal CT scanning. If the amount of blood injected was insufficient to cover the leakage area, a second EBP was performed at a later date.
Results
At the first EBP procedure, a mixture with a mean volume of 9.4 ml (range 3–20 ml) was injected, and subsequent spinal CT scans revealed contrast enhancement in the desired epidural space in 12 of 13 patients. In 2 patients, a second EBP was required because of insufficient coverage of the leakage area or delayed recurrence of headache. In all patients, a complete recovery from orthostatic headache was obtained after the last EBP.
Conclusions
The results indicated that fluoroscopically guided EBP and subsequent spinal CT scans may provide a highly effective therapy in patients with SCH proven on CT myelography studies.
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25
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Normal pressure form of the spontaneous intracranial hypotension: a case report with pituitary enlargement and asymptomatic pituitary haemorrhage. Neurol Sci 2011; 32:933-5. [PMID: 21484357 DOI: 10.1007/s10072-011-0584-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 04/04/2011] [Indexed: 10/18/2022]
Abstract
Spontaneous intracranial hypotension is a rare condition caused by spontaneous cerebrospinal fluid leak and volume depletion. It is initially misdiagnosed as a cause of an orthostatic headache, which is the most important symptom of the syndrome. It can be presented as one of four types: classic form, normal pressure form, normal pachymeninges form and acephalgic form. The diagnosis is made based on the clinical presentation, physical examination, typical cerebrospinal fluid and magnetic resonance imaging findings. We present a case of a 29-year-old woman with uncommon normal pressure form of the spontaneous intracranial hypotension, characterized by normal cerebrospinal fluid opening pressure, and typical clinical and magnetic resonance imaging findings, including the finding of pituitary gland enlargement with asymptomatic pituitary haemorrhage as an unusual complication.
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Franzini A, Zekaj E, Messina G, Mea E, Broggi G. Intracranial spontaneous hypotension associated with CSF cervical leakage successfully treated by lumbar epidural blood patch. Acta Neurochir (Wien) 2010; 152:1997-9. [PMID: 20740368 DOI: 10.1007/s00701-010-0783-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 08/17/2010] [Indexed: 10/19/2022]
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27
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Localization of thoracic CSF leaks by gadolinium-enhanced MR-myelography and successful MR-targeted epidural blood patching: a case report. J Neurol 2010; 257:1398-9. [DOI: 10.1007/s00415-010-5515-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 02/18/2010] [Accepted: 02/22/2010] [Indexed: 10/19/2022]
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28
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Clinical features and outcomes in spontaneous intracranial hypotension: a survey of 90 consecutive patients. Neurol Sci 2009; 30 Suppl 1:S11-3. [DOI: 10.1007/s10072-009-0060-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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29
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Mea E, Chiapparini L, Savoiardo M, Franzini A, Grimaldi D, Bussone G, Leone M. Application of IHS Criteria to Headache Attributed to Spontaneous Intracranial Hypotension in a Large Population. Cephalalgia 2009; 29:418-22. [DOI: 10.1111/j.1468-2982.2008.01747.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We applied the recent International Headache Society (IHS) criteria for headache related to spontaneous intracranial hypotension (SIH) to 90 consecutive patients with a final diagnosis of SIH confirmed by cerebral magnetic resonance imaging with contrast. Orthostatic headache (developing within 2 h of standing or sitting up) was present in 67 patients (75%) but appeared within 15 min after standing or sitting—as required by point A of the criteria—in only 53 (59%). Forty-four (49%) patients did not satisfy point A, including 22 (24%) with non-orthostatic headache and 14 (16%) with headache developing ≥ 15 min after standing or sitting up; 80 (89%) did not satisfy point D. Only three (3%) patients had headache fully satisfying the IHS criteria. These findings indicate that the current IHS criteria do not capture most patients with SIH-associated headache. Excluding the requirement for response to epidural blood patch (criterion D) and considering headaches appearing within 2 h of sitting or standing up would capture more patients.
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Affiliation(s)
- E Mea
- Neurological Institute ‘C. Besta’ Foundation, Milan
| | - L Chiapparini
- Department of Neuroradiology, University of Bologna Medical School, Bologna, Italy
| | - M Savoiardo
- Department of Neuroradiology, University of Bologna Medical School, Bologna, Italy
| | - A Franzini
- Department of Neurosurgery, University of Bologna Medical School, Bologna, Italy
| | - D Grimaldi
- Department of Neurological Sciences, University of Bologna Medical School, Bologna, Italy
| | - G Bussone
- Neurological Institute ‘C. Besta’ Foundation, Milan
| | - M Leone
- Neurological Institute ‘C. Besta’ Foundation, Milan
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30
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JENSEN U, ULMER S, TIETKE M, JANSEN O. Double vision. Differentials please! Br J Radiol 2009; 82:173-4. [DOI: 10.1259/bjr/59515621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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31
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Abstract
Spontaneous intracranial hypotension is a rare syndrome of low cerebrospinal fluid pressure due to spontaneous cerebrospinal fluid leaks. The main feature is orthostatic headache. We describe a case of spontaneous intracranial hypotension in a 5-year-old girl with a 1-month history of headache, sudden onset hearing loss, and ataxia. Magnetic resonance imaging (MRI) showed an enlargement of cervical venous plexus and lumbar puncture revealed a low opening pressure. Magnetic resonance myelography showed leakage of the contrast material at the level of the third and fourth lumbar vertebra. Bed rest and caffeine treatment yielded no resolution of symptoms. Following a lumbar epidural blood patch, her headache and ataxia resolved completely without any improvement in hearing. A second blood patch also yielded no effect on hearing. Spontaneous intracranial hypotension should be considered in the differential diagnosis of headache, also in the pediatric age group.
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Affiliation(s)
- Serap Uysal
- Istanbul University Cerrahpasa Medical Faculty, Department of Neuroradiology, Istanbul, Turkey
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32
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Pasquale LR. Low intracranial pressure: a tipping point in our understanding of primary open-angle glaucoma? Ophthalmology 2008; 115:761-2. [PMID: 18452761 DOI: 10.1016/j.ophtha.2008.01.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Accepted: 01/05/2008] [Indexed: 11/27/2022] Open
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Molina R, Nogués P, Montoliu G. Casos en imagen 1.—Hipotensión intracraneal espontánea. RADIOLOGIA 2008; 50:196; discussion 251. [DOI: 10.1016/s0033-8338(08)71973-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Townend E, Brady M, McLaughlan K. A Systematic Evaluation of the Adaptation of Depression Diagnostic Methods for Stroke Survivors Who Have Aphasia. Stroke 2007; 38:3076-83. [DOI: 10.1161/strokeaha.107.484238] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Ellen Townend
- From the NMAHP Research Unit (E.T., M.B.), Buchannan House, Glasgow Caledonian University, UK; and the NHS Grampian (K.N.), Department of Speech and Language Therapy, Spynie Hospital, Morayshire, UK
| | - Marian Brady
- From the NMAHP Research Unit (E.T., M.B.), Buchannan House, Glasgow Caledonian University, UK; and the NHS Grampian (K.N.), Department of Speech and Language Therapy, Spynie Hospital, Morayshire, UK
| | - Kirsty McLaughlan
- From the NMAHP Research Unit (E.T., M.B.), Buchannan House, Glasgow Caledonian University, UK; and the NHS Grampian (K.N.), Department of Speech and Language Therapy, Spynie Hospital, Morayshire, UK
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35
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TAKEUCHI S, TAKASATO Y, MASAOKA H, HAYAKAWA T, OTANI N, YOSHINO Y, YATSUSHIGE H. Spontaneous Intracranial Hypotension Associated With Dural Sinus Thrombosis -Case Report-. Neurol Med Chir (Tokyo) 2007; 47:555-8. [DOI: 10.2176/nmc.47.555] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Satoru TAKEUCHI
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center
| | - Yoshio TAKASATO
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center
| | - Hiroyuki MASAOKA
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center
| | - Takanori HAYAKAWA
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center
| | - Naoki OTANI
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center
| | - Yoshikazu YOSHINO
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center
| | - Hiroshi YATSUSHIGE
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center
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36
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Wiesemann E, Berding G, Goetz F, Windhagen A. Spontaneous Intracranial Hypotension: Correlation of Imaging Findings with Clinical Features. Eur Neurol 2006; 56:204-10. [PMID: 17057379 DOI: 10.1159/000096487] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Accepted: 07/20/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is increasingly recognized as a clinically variable and likely underdiagnosed syndrome caused by non-traumatic CSF leaks. The aim of this study was to correlate the findings of imaging studies - magnetic resonance imaging (MRI), radionuclide cisternography - with clinical features and CSF pressure in SIH in order to improve the diagnostic yield and management in patients with SIH. METHODS Clinical case study of 10 consecutive cases of SIH, MRI, radio-isotope cisternography. RESULTS 5 out of 10 patients had unusual clinical symptoms of SIH(2 subdural haematomas, 1 gait ataxia, 1 tinnitus, 1 haemodialysis-associated headache). In 7 patients pachymeningeal gadolinium enhancement was detected in MRI accompanied by a reduced CSF opening pressure. In contrast, the 3 patients with normal MRI also had a normal CSF pressure. Radio-isotope cisternography was abnormal in all patients tested. There was no correlation between the severity of clinical symptoms and MRI or radionuclide cisternography findings. CONCLUSIONS The spectrum of clinical symptoms and imaging findings in SIH is highly variable. There- fore the diagnosis of SIH is often delayed. Radio-isotope cisternography is an important additional diagnostic method to detect CSF leaks or pathological kinetics of radio-isotope movement particularly in cases with normal MRI findings.
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Affiliation(s)
- Elke Wiesemann
- Department of Neurology, Medical School Hannover, Hannover, Germany
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37
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Liu JK, Gottfried ON, Brockmeyer DL. Epidural venous engorgement resulting in progressive cervical myelopathy from shunt-related intracranial hypotension. J Neurosurg Pediatr 2006; 105:499-503. [PMID: 17184086 DOI: 10.3171/ped.2006.105.6.499] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report an unusual case of engorged epidural veins causing progressive cervical myelopathy after long-term cerebrospinal fluid (CSF) shunt therapy and intracranial hypotension. An 18-year-old woman, who had previously undergone shunt placement with a distal slit valve for a porencephalic cyst when 2 years of age, presented with progressive spastic quadriparesis, numbness, and gait difficulty. Postural headaches were absent and a lumbar puncture revealed low CSF pressure. Neuroimaging disclosed markedly engorged anterior epidural veins causing compression of the cervical spinal cord. The slit-valve shunt system was surgically removed and an external drain was placed. The patient's CSF pressure was gradually raised to clinically tolerable levels. Once the optimal pressure was identified, a programmable shunt was placed with the valve set at the same level. The patient's neurological status improved, and the epidural veins had returned to their normal size on follow-up imaging. The authors describe the unique treatment strategy used in this patient and review the literature on epidural venous engorgement as it relates to intracranial hypotension.
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Affiliation(s)
- James K Liu
- Department of Neurosurgery, University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, Utah 84113, USA
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38
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Jia H, Damush TM, Qin H, Ried LD, Wang X, Young LJ, Williams LS. The Impact of Poststroke Depression on Healthcare Use by Veterans With Acute Stroke. Stroke 2006; 37:2796-801. [PMID: 17008625 DOI: 10.1161/01.str.0000244783.53274.a4] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Poststroke depression (PSD) is common among stroke survivors, and it is associated with worse functional outcomes and increased poststroke mortality. Limited information is available about its impact on healthcare use. This study assessed the impact of PSD on healthcare use by veterans with acute stroke. METHODS In this retrospective, observational national study, 5825 veterans with acute stroke were identified from Veterans Affairs' (VA) inpatient databases. To determine the patients' comprehensive PSD and use status, VA and Medicare fee-for-service inpatient and outpatient as well as VA pharmacy data were used. PSD was established if a patient had an inpatient or outpatient depression diagnosis or if a patient received one of the antidepressants within the VA 12 months postindex stroke. Healthcare use referred to the number of hospital stays, outpatient visits, and cumulative length of inpatient stays under both VA and Medicare fee-for-service programs. Poisson regression was fitted to estimate the impact of PSD on use controlling for sociodemographic, clinical, and disease severity factors. RESULTS Forty-one percent of the sample had PSD. After adjusting for patient demographic and clinical factors, we found that the patients with stroke with PSD had significantly (P<0.0001) more hospitalizations, outpatient visits, and longer length of stays 12 months poststroke compared with these patients with stroke without PSD. CONCLUSIONS Patients with PSD had greater 12-month poststroke healthcare use even when controlling for other demographic and clinical variables. Early detection and appropriate management of PSD for veterans with acute stroke may help reduce their poststroke healthcare use.
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Affiliation(s)
- Huanguang Jia
- VA Stroke QUERI Research Coordinating Center, Gainesville, Florida, USA.
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Shrikrishna D, Green C, Wood D, Handel J. Life-threatening spontaneous intracranial hypotension responding to epidural blood patch. Br J Anaesth 2006; 97:750. [PMID: 17032670 DOI: 10.1093/bja/ael262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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40
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Inamasu J, Guiot BH. Intracranial hypotension with spinal pathology. Spine J 2006; 6:591-9. [PMID: 16934734 DOI: 10.1016/j.spinee.2005.12.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2005] [Revised: 11/19/2005] [Accepted: 12/30/2005] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intracranial hypotension (IH) is a syndrome in which volume depletion of the cerebrospinal fluid (CSF) results in various neurological symptoms. Most commonly, a small tear or defect in the spinal dural sac is the underlying lesion that results in a CSF leakage and IH. Causes of IH can be classified as 1) spontaneous (primary), and 2) secondary. Knowledge of IH is essential to spine surgeons, because a small proportion of patients with spontaneous IH require spine surgery, and secondary causes of IH include spine trauma, various spine-related diagnostic/therapeutic procedures (iatrogenic), and degenerative spine disorders. PURPOSE The purpose of this review is to update knowledge of IH pertinent to spine surgery. STUDY DESIGN/SETTING Review of the literature. METHODS A systematic review of the literature was conducted using PUBMED. The literature regarding IH with spinal pathology published from 1966 to 2005 was searched and reviewed comprehensively. RESULTS/CONCLUSIONS The lower cervical and upper thoracic spine are the predilection sites for a CSF leak in patients with spontaneous IH. Mechanical stress may have a role in the pathogenesis of spontaneous IH, and meningeal diverticula and connective tissue disorders may be important risk factors. Iatrogenic causes of IH include lumbar puncture, spine surgery, and chiropractic manipulation. Rarely, degenerative spine disorders are the secondary cause of IH. Although orthostatic headache is the characteristic symptom of IH, a small proportion of patients present with neck pain or radicular symptoms of the upper extremity. Imaging studies of the spine have contributed significantly to elucidation of the pathophysiology of IH as well as identification of the site of a CSF leak. Typical spinal radiographic findings of IH include extra-arachnoid or extradural fluid collections, meningeal enhancement, engorgement of the epidural venous plexus, and tonsilar descent into the foramen magnum. Most patients with spontaneous IH respond favorably to conservative management, including autologous epidural blood patch. Surgical intervention is reserved for those who fail the conservative management. Although immediate clinical improvement is usually achieved by surgery, the long-term outcomes of surgical patients need to be investigated further. In patients who have a secondary cause of IH, treatment of the underlying lesion or condition may terminate a CSF leak and result in reversal of symptoms.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, University of South Florida College of Medicine, Tampa, FL 33606, USA.
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Maraval A, Brugieres P, Combes C, Thomas P, Blanc R, Gaston A. Exploration de l’hypotension de liquide cérébro-spinal à l’étage rachidien en IRM. J Neuroradiol 2006; 33:184-8. [PMID: 16840961 DOI: 10.1016/s0150-9861(06)77257-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We propose studying signs of cervicothoracic CSF hypotension by MRI. Axial T1-weighted GRE sequence with and without saturation bands positioned above and below the selected image plane, MR venography and MR Angiography with contrast administration are helpful to confirm the venous nature of the epidural thickening and to make the differential diagnosis with infectious or neoplastic epiduritis.
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Affiliation(s)
- A Maraval
- CHU Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil
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