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

Dural Arteriovenous Fistulas in Spontaneous Intracranial Hypotension

The occurrence of dural arteriovenous fistulas (DAVFs) in patients with spontaneous intracranial hypotension (SIH) is exceptionally rare. While DAVF is a known complication of cerebral venous thrombosis (CVT), the role of CVT as one of the early events in the genesis of DAVFs is still debated. This is because only a small number of patients with CVT develop DAVFs, and not all DAVFs are associated with CVT. Although several hypotheses have been proposed to explain the link between CVT and DAVFs, the relationship between DAVFs and SIH in the absence of CVT remains unclear. To delineate the association between DAVFs and SIH. We reviewed the medical records of 460 SIH patients who were observed and treated over the past several years, looking specifically for cases of SIH complicated by DAVFs. We also reviewed all published case reports reporting patients with SIH and DAVFs. Of the 460 SIH patients reviewed, two (0.4%) were also diagnosed with DAVFs. Both patients had orthostatic headache, diffuse pachymeningeal enhancement, and brain sagging on brain magnetic resonance imaging, which are typical neuroimaging findings of SIH. Patient n.1 reported DAVF caused by left transverse/sigmoid sinus thrombosis, while patient n.2 presented DAVF as a complication of SIH in the absence of CVT. We speculate that SIH, even without CVT, might represent the start of a cascade of events leading to DAVFs. The pathogenic mechanism involved in DAVF formation in SIH patients could be explained by the opening of preexisting microscopic vascular channels within the dura mater, secondary to extreme venodilation related to SIH.

Iatrogenic intracranial hypotension complicated to dural venous sinus thrombosis and lobar hemorrhage: A case report

Iatrogenic intracranial hypotension is a known complication of spinal anesthesia that can lead to more severe conditions, such as dural or cerebral venous sinus thrombosis (CVST). This report presents a case of intracranial hypotension in a young woman after lumbar anesthesia for a cesarean section that was complicated by CVST and subsequently by lobar hemorrhage, clinically presenting with severe headache and seizures. The diagnosis was made via cerebral magnetic resonance (MR) imaging, and the patient was treated medically. This case study aimed to assist clinicians in considering the possible complications of intracranial hypotension when evaluating patients with a recent history of spinal procedures, leading to early diagnosis and treatment to prevent devastating consequences.

Update on management of cerebral venous thrombosis

PURPOSE OF REVIEW

This review intends to systematize the diagnostic and treatment approach to cerebral venous thrombosis (CVT), highlighting key studies that have been recently published.

RECENT FINDINGS

In light of the recent pandemic, new risk factors for CVT have emerged. Contrast-enhanced MRI and susceptibility-weighted imaging have been shown to offer increased sensitivity for detecting cortical vein thrombosis.Dabigatran seems to be as effective and well tolerated as warfarin for long-term anticoagulation. Partial venous recanalization often occurs in patients treated with anticoagulation only, as early as 8 days after treatment onset. For patients with CVT and impending brain herniation, two-thirds of those who undergo decompressive craniectomy survive, with one-third being functionally independent 6 months after diagnosis.

SUMMARY

CVT is an unusual type of cerebrovascular disease that mostly affects women of fertile age. Risk factors should be identified and addressed. Diagnosis relies on confirmation of venous sinus and/or vein thrombosis, usually by CT venography or MRI. Anticoagulation is the cornerstone of treatment. Despite the lack of high-quality evidence, endovascular treatment is often considered in severe cases. Special populations require tailored approaches. About 80% achieve mRS 0-1, but residual symptoms often affect quality of life and the ability to return to work.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Cerebral venous thrombosis after lumboperitoneal shunting: A case report

Lumboperitoneal shunt (LPS) has been an effective treatment of idiopathic normal pressure hydrocephalus (iNPH) but sometimes causes serious complications. Here we present the first reported case of cerebral venous thrombosis (CVT) after LPS. A 76-year-old man underwent LPS for iNPH and a week later developed weakness of the right arm and a generalized tonic-clonic seizure. Brain computed tomography and magnetic resonance imaging showed bilateral subdural hematoma (SDH) and left cortical vein thrombosis. Intravenous heparin was administered, followed by surgical evacuation of the SDH. The patient experienced gradual improvement and was subsequently discharged. It is conceivable that overdrainage of cerebrospinal fluid led to the development of both SDH and CVT. CVT is potentially fatal and should be recognized early as a possible complication after LPS to allow prompt treatment.

Prevalence, clinical presentation, and treatment-management of cerebral venous thrombosis associated with spontaneous intracranial hypotension: A combined case-series and systematic literature review approach

BACKGROUND

Cerebral venous thrombosis (CVT) is a rare complication of spontaneous intracranial hypotension (SIH). Therefore, its correct diagnosis and the corresponding optimal treatment-management identification remains challenging.

METHODS

Over the last 10 years, 300 patients received a definite SIH diagnosis at our stroke center. Through thorough review of the database, we identified all patients with SIH-related CVT. In addition, we performed a systematic literature review including all publications on SIH-related CVT.

RESULTS

Five out of our 300 SIH patients showed CVT (F/M:2/3, mean age: 51.8 ± 15.7). Through the literature search, 72 additional cases were identified. Overall, the prevalence was 1.3% and main clinical presentations were orthostatic headache, nausea, and vomiting. The CVT was predominantly located at the superior sagittal sinus. Treatment strategies included anticoagulants (ACs) (43%), epidural blood patch (EBP) (19.4%), and combined AC + EBP (33.3%). In our cohort, all but one patient received combined EBP and AC. The mean clinical and radiological follow-up were 2 years and 1.5 years, respectively. Complete clinical recovery was reported in 96% of the cases, whereas 56% showed complete radiological CVT resolution. Among patients without radiological resolution (26.4%), 57% received AC-only, while 43% received combined AC + EBP. Of our five cases, all but one patient received combined AC + EBP.

CONCLUSION

The overall prevalence of SIH-related CVT was 1.3%. AC and combined AC + EBP were the most used treatment-management strategies. CVT resolution was more commonly achieved after the combined strategy. Overall, the rate of complete clinical recovery was 96%.

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.