Organic bipolar disorder occurring together with spontaneous intracranial hypotension

Multilevel, ultra-large-volume epidural blood patch for the treatment of neurocognitive decline associated with spontaneous intracranial hypotension: case report

Spontaneous intracranial hypotension (SIH) is a progressive clinical syndrome characterized by orthostatic headaches, nausea, emesis, and occasionally focal neurological deficits. Rarely, SIH is associated with neurocognitive changes. An epidural blood patch (EBP) is commonly used to treat SIH when conservative measures are inadequate, although some patients require multiple EBP procedures or do not respond at all. Recently, the use of a large-volume (LV) EBP has been described to treat occult leak sites in treatment-refractory SIH. This article describes the management of a patient with profound neurocognitive decline associated with SIH, who was refractory to conservative management and multiple interventions. The authors describe the successful use of an ultra-LV-EBP of 120 ml across multiple levels, the largest volume reported in the literature, and describe the technical aspects of the procedure. This procedure has resulted in dramatic and sustained symptom resolution.

Unsuccessful tracer injection in radionuclide cisternography revisited

Since cerebrospinal fluid (CSF) leakage is highlighted as a cause of persistent headache, radionuclide cisternography has been increasingly performed in Japan to confirm the disorder, although the limited ability of the examination should be recognized. We present 3 cases in which failure of a tracer injection was strongly suspected. In 2 cases with chronic symptoms, the tracer appeared to be injected into the epidural space, because of irregular initial accumulation of the tracer and lack of diffusion along the CSF cavity. Another is a case with spontaneous CSF leakage confirmed by MRI, and the tracer was thought to be injected into the leaked fluid accumulated in the spinal epidural space. Tracer in the CSF space rapidly disappeared within several hours in all cases. As such cisternographic images may be misdiagnosed as severe CSF leakage, careful interpretation of images in patients especially with no typical MR findings of CSF leakage is necessary. Excessive tracer clearance from the body suggests such technical failure.

Jugular Compression and Radionuclide Cisternographic Patterns in Patients With Chronic Headache

OBJECTIVE

We investigated the value of the jugular compression test (JCT) in screening patients with chronic headache attributable to persistent cerebrospinal fluid (CSF) leakage.

METHODS

Clinical records of 35 consecutive patients who underwent both 111In-diethylenetriamine pentaacetic acid radioisotope (RI) cisternography and JCT were retrospectively analyzed.

RESULTS

A strong correlation was seen between JCT and RI cisternographic findings. Most patients who reported a feeling of fullness in the ear, hearing loss or headache during JCT had positive findings on RI cisternograms indicative of CSF leakage. In contrast, no RI study abnormalities were seen in patients reporting no symptoms in JCT.

CONCLUSIONS

Among patients complaining of refractory headache and other miscellaneous symptoms, JCT may represent a simple, economic, and reliable technique in the screening of candidates for RI cisternography to evaluate CSF leakage. A subgroup of patients with chronic headache may have persistent CSF leakage.