Cerebral venous thrombosis in spontaneous intracranial hypotension: A report of 8 cases and review of the literature

Spontaneous Intracranial Hypotension in Pregnancy

PURPOSE OF REVIEW

Spontaneous intracranial hypotension (SIH) is a debilitating disease typically featuring orthostatic headache and caused by a spinal CSF leak. This review will describe the characteristics of SIH in pregnant patients and the associated unique management and treatment considerations.

RECENT FINDINGS

Herein, a novel case is reported of a 41-year-old woman who presented with SIH pre-conception but saw marked improvement of symptoms after 5 weeks antepartum and symptom recurrence 2 months post-partum. A literature review of SIH in pregnancy revealed 14 reported patients across 10 studies since 2000. All the reported cases resulted in delivery of healthy infants and symptomatic improvement with conservative management or a variety of treatment modalities including non-targeted epidural blood patch (EBP). Clinical and imaging features of SIH in pregnancy are reviewed. We hypothesize an antenatal protective mechanism against SIH symptoms through cephalad redistribution of CSF volume from the spinal to intracranial compartments related to uterine growth and decreased CSF volume within the lumbar cistern. Treatment recommendations are discussed including duration of bed rest and decision for non-targeted multi-site EBPs. When required, non-invasive diagnostic spine MRI using fat-suppressed axial T2-weighted imaging may be helpful.

Rare cause of cerebral venous sinus thrombosis: Spontaneous intracranial hypotension syndrome: A case report

BACKGROUND

Spontaneous intracranial hypotension syndrome is a relatively uncommon neurological disorder of unknown etiology with a good prognosis. Cerebral venous sinus thrombosis is a specific type of cerebrovascular disease caused by multiple etiologies of cerebral venous sinus or vein thrombosis that obstructs cerebral venous return and is associated with impaired cerebrospinal fluid absorption; this entity is rarely seen clinically. Spontaneous intracranial hypotension syndrome is one of the causes of cerebral venous sinus thrombosis, and the probability of their combined occurrence is only 1%-2%. As such, it is easily overlooked clinically, thus increasing the difficulty of diagnosis and treatment.

CASE SUMMARY

A 29-year-old young woman presented with postural headache. Lumbar puncture suggested a pressure of 50 mmH₂O (normal 80 mmH₂O-180 mmH₂O), and magnetic resonance imaging cerebral venography suggested thrombosis of the supratentorial sinus. These findings were considered indicative of cerebral venous sinus thrombosis due to spontaneous intracranial hypotension syndrome after ruling out immunological causes, tumor, infection, abnormal coagulation mechanism, and hypercoagulable state, etc. She was treated with rehydration and low-molecular heparin anticoagulation for 15 d, and follow-up magnetic resonance imaging cerebral venography suggested resolution of the thrombus. The patient had complete improvement of her headache symptoms.

CONCLUSION

Spontaneous intracranial hypotension syndrome is one of the rare causes of cerebral venous sinus thrombosis, which is frequently misdiagnosed or missed and deserves consideration by clinicians during differential diagnosis. Dehydration should be avoided in such patients, and early rehydration and anticoagulation therapy are effective treatment options.

Spontaneous intracranial hypotension: updates from diagnosis to treatment

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.

Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes

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.