Spontaneous Intracranial Hypotension Is Associated with a Risk of Venous Sinus Thrombosis and Subdural Hematoma

Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening

PURPOSE

To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility.

METHODS

In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen's kappa statistics, interobserver agreement was assessed.

RESULTS

In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39).

CONCLUSION

The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.

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

BACKGROUND

The occurrence of cerebral venous thrombosis (CVT) in patients with spontaneous intracranial hypotension (SIH) raises difficult practical questions regarding the management of the two conditions. The first-line therapy for CVT is anticoagulation (AC); however, its potential benefit in SIH/CVT patients, especially if complicated by subdural haematoma, must be carefully evaluated taking account of the intracranial haemorrhage risk. Venous system recanalization and good prognosis in SIH/CVT patients treated with epidural blood patch (EBP), the main treatment option for SIH, have been already described.

METHODS

We reviewed our cases of SIH complicated by CVT among a cohort of 445 SIH patients observed and treated during the last years. All published case reports and case series reporting patients with SIH and CVT were also ascertained and reviewed.

RESULTS

Eight (2%) out of 445 patients suffering with SIH, were also diagnosed with CVT. All patients observed had orthostatic headache, three of them experienced a change in their headache pattern over the SIH course. Six out of eight patients received both AC and EBP treatments. Two patients were treated using only AC or EBP. A bilateral subdural haematoma enlargement after 1 month of AC was observed in one case. Complete CVT recanalization after treatment was obtained in three patients, including two with multiple CVT at baseline; partial CVT recanalization was achieved in two patients. Three patients experienced no CVT recanalization. After 6-48 months' follow-up all patients were still asymptomatic.

CONCLUSIONS

The use of AC therapy should be weighed against the intracranial haemorrage risk and should be monitored carefully if initiated. Effective and prompt EBP, even without AC therapy, might lead to a good prognosis in selected cases.

Cerebral venous sinus thrombosis following post-neurosurgical intracranial hypotension: A case report and systematic review of the literature

Cerebral venous sinus thrombosis (CVST) following brain surgery is a feared complication, commonly described after direct injury to the sinus. However, distant CVST occurring away from the operative area are unexpected. Yet, there is a strong physio-pathological rational supporting the role of intracranial hypotension as a risk factor of CVST. Here, we report the case of a frontal arachnoid cyst depletion followed by an extensive contralateral CVST. Given the major prognostic consequences observed in this clinical illustration, we further investigated the hypothesis of intracranial hypotension as an etiology of CVST by carrying out a systematic review of the literature.

Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report

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.

Spontaneous intracranial hypotension associated with cerebral venous thrombosis detected by a sudden seizure: a case report

Background

Spontaneous intracranial hypotension (SIH) is rare but can lead to life-threatening complications including cerebral venous thrombosis (CVT). The concurrence of CVT and SIH raises questions regarding priority.

Case presentation

We present the case of a 52-year-old woman who developed sudden left-sided hemiparesis and generalized tonic-clonic seizures. She experienced progressive orthostatic headaches over the prior 2 weeks. Imaging showed thrombosis in the left transverse and sigmoid sinuses, bilateral subdural hematomas, and a cervicothoracic cerebrospinal fluid leak. Low molecular weight heparin was administered, but it was discontinued 2 days later due to subarachnoid hemorrhage. She was transferred to our hospital where an epidural blood patch was applied immediately, which resulted in complete symptom relief.

Conclusion

CVT is a rare complication of SIH that may result in devastating consequences. Treatment of SIH should be the primary focus. Prompt diagnosis and EBP application can result in a good outcome.

Spontaneous Intracranial Hypotension: Atypical Radiologic Appearances, Imaging Mimickers, and Clinical Look-Alikes

Spontaneous intracranial hypotension is a condition characterized by low CSF volume secondary to leakage through a dural defect with no identifiable cause. Patients classically present with orthostatic headaches, but this symptom is not specific to spontaneous intracranial hypotension, and initial misdiagnosis is common. The most prominent features of spontaneous intracranial hypotension on intracranial MR imaging include "brain sag" and diffuse pachymeningeal enhancement, but these characteristics can be seen in several other conditions. Understanding the clinical and imaging features of spontaneous intracranial hypotension and its mimickers will lead to more prompt and accurate diagnoses. Here we discuss conditions that mimic the radiologic and clinical presentation of spontaneous intracranial hypotension as well as other disorders that CSF leaks can imitate.

Management of Subdural Hematohygromas in Abusive Head Trauma

BACKGROUND

The optimal management of nonacute subdural fluid collections in infantile abusive head trauma (AHT) remains controversial.

OBJECTIVE

To review the outcomes and costs of the various treatments for symptomatic subdural fluid collections in children with AHT at a single center.

METHODS

Our AHT database was queried to identify children requiring any intervention for hematohygromas. Demographic, hospital course, radiologic, cost, readmission, and follow-up information were collected.

RESULTS

From January 2009 to March 2018, the authors identified 318 children with AHT, of whom 210 (66%) had a subdural collection of any type (blood or cerebrospinal fluid). A total of 50 required some form of intervention specifically for chronic hematohygromas. The initial management consisted of transfontanelle percutaneous aspiration (n = 31), burr holes with (n = 12) or without (n = 3) external subdural drainage, and mini-craniotomy (n = 4). Of those who were initially managed with 1 or more needle aspiration, 23 (74%) required further intervention-12 subduroperitoneal shunts and 11 nonshunt procedures. No patient who underwent burr holes/external drainage required further intervention (n = 16). Overall, the average number of interventions needed in these 50 children for definitive treatment was 1.8 (range, 1-4). A total of 15 children ultimately required a subduroperitoneal shunt. Complications (infectious, hemorrhagic, and thrombotic) were significant and occurred in all treatment groups except burr holes without drainage (n = 3). The average hospital charge for the entire cohort was $166 300.25 (range, $19 126-$739 248).

CONCLUSION

Based on our experience to date, burr hole with controlled external subdural drainage is an effective and preferred treatment for traumatic hematohygromas; complications and need for additional intervention is low.

MRI Findings of Spontaneous Intracranial Hypotension: Usefulness of Straight Sinus Distention

OBJECTIVE. Spontaneous intracranial hypotension (SIH) shows various characteristic MRI findings. We evaluated the usefulness of straight sinus distention compared with transverse sinus distention and also evaluated other MRI findings of SIH. MATERIALS AND METHODS. Forty-three consecutive patients (28 female and 15 male patients) treated for SIH and 43 age- and sex-matched control subjects at two institutions from 2012 through 2014 were included in this study. Two reviewers determined whether the transverse sinus distention sign and straight sinus distention sign were present on MRI. Diagnostic performance values and interobserver agreement were calculated. Reviewers also assessed MRI examinations in consensus for the presence of the following findings: pachymeningeal enhancement, subdural effusion or hematoma, enlargement of the pituitary gland, and downward displacement of the brainstem and tonsils. RESULTS. The sensitivity, specificity, and diagnostic accuracy of the transverse sinus distention sign for SIH were 76.7%, 83.7%, and 80.2%, whereas those of the straight sinus distention sign were 79.1%, 95.4%, and 87.2%, respectively. The specificity of the straight sinus distention sign for SIH was significantly higher (p = 0.025) than that of the transverse sinus distention sign. In addition, the straight sinus distention sign showed substantial agreement (κ = 0.79), whereas the transverse sinus distention sign showed moderate agreement (κ = 0.60). The diagnostic accuracy of the presence of either transverse or straight sinus distention (83.7%) was significantly higher than that of pachymeningeal enhancement (80.2%, p = 0.032). CONCLUSION. The straight sinus distention sign could be helpful for the diagnosis of SIH because it has sensitivity comparable to other imaging findings and higher specificity and higher level of interobserver agreement than other imaging findings.

Cerebral Venous Thrombosis in Spontaneous Intracranial Hypotension: A Report on 4 Cases and a Review of the Literature

OBJECTIVE

Spontaneous intracranial hypotension is a risk factor for cerebral venous thrombosis. The occurrence of cerebral venous thrombosis in patients with spontaneous intracranial hypotension raises difficult practical questions regarding the management of the 2 conditions. We reviewed our experience and the relevant literature to evaluate these related questions.

METHODS

We retrospectively studied the medical records and imaging studies of patients with spontaneous intracranial hypotension at a tertiary center from January 2007 through January 2017. The main search strategy was a literature review of journal articles in PubMed (1966 to January 2017).

RESULTS

Among 374 patients with spontaneous intracranial hypotension, 4 were also diagnosed with cerebral venous thrombosis. A literature review yielded an additional 31 cases, including 21 men and 14 women with a mean age of 40.6 years. Of the 35 patients, 8 (22.8%) patients received anticoagulation therapy and epidural blood patch. Nineteen (54.3%) patients were given anticoagulant only. Seven (20%) patients were treated with epidural blood patch only. One (2.9%) patient did not receive epidural blood patch or anticoagulation therapy. There is no difference in terms of age, sex, diagnosis interval, association with other complications, and prognosis between the first 3 groups. Of the 19 patients who received anticoagulation therapy, 4 patients (21.1%) had intracranial hemorrhage or hematoma enlargement after anticoagulation, and one of these 4 patients died following further intracranial hemorrhage. Of the 8 patients who received both anticoagulation and epidural blood patch, 1 patient (12.5%, P = 0.528) developed subdural hematoma after anticoagulation. Of the 5 cases had intracranial hemorrhage aggravation after anticoagulation, 4 were subdural hematoma occurrence or enlargement.

CONCLUSION

Cerebral venous thrombosis is a rare but important complication of spontaneous intracranial hypotension. The primary focus of treatment should be the treatment of intracranial hypotension. It could be possible that anticoagulation might increase the risk of intracranial hemorrhage in patients with spontaneous intracranial hypotension, although a firm conclusion could not be drawn based on the limited number of patients currently available. The use of anticoagulation therapy should be prudent and should be monitored carefully if initiated.

Spontaneous occult intracranial hypotension precipitating life-threatening cerebral venous thrombosis: case report

Spontaneous intracranial hypotension (SIH) is an uncommon headache etiology, typically attributable to an unprovoked occult spinal CSF leak. Although frequently benign, serious complications may occur, including cerebral venous thrombosis (CVT). The objective of this study was to examine a highly complicated case of CVT attributable to SIH as a lens for understanding the heterogeneous literature on this rare complication, and to provide useful, evidence-based, preliminary clinical recommendations. A 43-year-old man presented with 1 week of headache, dizziness, and nausea, which precipitously evolved to hemiplegia. CT venography confirmed CVT, and therapeutic heparin was initiated. He suffered a generalized seizure due to left parietal hemorrhage, which subsequently expanded. He developed signs of mass effect and herniation, heparin was discontinued, and he was taken to the operating room for clot evacuation and external ventricular drain placement. Intraoperatively, the dura was deflated, suggesting underlying SIH. Ventral T-1 CSF leak was identified, which failed multiple epidural blood patches and required primary repair. The patient ultimately made a complete recovery. Systematic review identified 29 publications describing 36 cases of SIH-associated CVT. Among 31 patients for whom long-term neurological outcome was reported, 25 (81%) recovered completely. Underlying coagulopathy/risk factors were identified in 11 patients (31%). CVT is a rare and potentially lethal sequela occurring in 2% of SIH cases. Awareness of the condition is poor, risking morbid complications. Evaluation and treatment should be directed toward identification and treatment of occult CSF leaks. Encouragingly, good neurological outcomes can be achieved through vigilant multidisciplinary neurosurgical and neurocritical care.

Cerebral venous thrombosis in two patients with spontaneous intracranial hypotension

Although few patients with spontaneous intracranial hypotension develop cerebral venous thrombosis, the association between these two entities seems too common to be simply a coincidental finding. We describe two cases of spontaneous intracranial hypotension associated with cerebral venous thrombosis. In one case, extensive cerebral venous thrombosis involved the superior sagittal sinus and multiple cortical cerebral veins. In the other case, only a right frontoparietal cortical vein was involved. Several mechanisms could contribute to the development of cerebral venous thrombosis in spontaneous intracranial hypotension. When spontaneous intracranial hypotension and cerebral venous thrombosis occur together, it raises difficult practical questions about the treatment of these two conditions. In most reported cases, spontaneous intracranial hypotension was treated conservatively and cerebral venous thrombosis was treated with anticoagulation. However, we advocate aggressive treatment of the underlying cerebrospinal fluid leak.

Evaluation on a clinical course of subdural hematoma in patients undergoing epidural blood patch for spontaneous cerebrospinal fluid leak

OBJECTIVE

Subdural hematoma (SDH) is a frequent complication of spontaneous intracranial hypotension (SIH), in which epidural blood patch (EBP) may be applied as a treatment to stop cerebrospinal fluid (CSF) leak. However, a clinical course of SDH in SIH patients has not been sufficiently evaluated. We retrospectively evaluated the temporal relationships between EBP and SDH in the patients with SIH.

METHODS

Twenty-nine consecutive patients, diagnosed as SIH, were studied. Clinical records and images were retrospectively evaluated. When orthostatic headache continued for 2 weeks regardless of conservative treatment, EBP was performed under fluoroscopy.

RESULTS

We detected 13(45%) cases of SDH (mean age 44 years, 8 males and 5 females). In 6 patients, SDHs disappeared after effective EBP, i.e., after the disappearance of orthostatic headache. In 3 patients, SDHs were enlarged or recurred after effective EBP, and in 4 patients, SDHs were first detected after effective EBP.

CONCLUSION

The knowledge of the presence of these types of SDH (enlarged or recurred or detected after EBP) may deserve clinical attention.

Sinus thrombosis in a patient with intracranial hypotension: a suggested hypothesis of venous stasis. a case report

We describe the case of a 26-year-old man with orthostatic headache. Cerebral angiography revealed thrombosis in the sagittal sinus. Spine MRI showed cerebrospinal fluid collection at the C1-2 level. We performed blood patch and the symptoms disappeared. We report a rare case of intracranial hypotension caused by CSF leak and describe our hypothesis that SIH can change the velocity of cerebral blood flow and cause thrombosis.

Subdural hematoma in a patient with spontaneous intracranial hypotension and cerebral venous thrombosis

We report a patient with clinical and neuroimaging findings of spontaneous intracranial hypotension (SIH) who developed cerebral venous thrombosis (CVT). An association between SIH and CVT has rarely been observed. Anticoagulation therapy was administered. The clinical course was subsequently complicated by a large subdural hematoma that required neurosurgical evacuation. The present report indicates that SIH should not be always considered a benign condition, especially when associated with CVT and subdural fluid collections. Furthermore, clinicians should be aware of the potential risks of anticoagulant therapy in patients with SIH and CVT.

Diffuse pachymeningeal hyperintensity and subdural effusion/hematoma detected by fluid-attenuated inversion recovery MR imaging in patients with spontaneous intracranial hypotension

BACKGROUND AND PURPOSE

Fluid-attenuated inversion recovery (FLAIR) MR imaging has advantages to detect meningeal lesions. FLAIR MR imaging was used to detect pachymeningeal thickening and thin bilateral subdural effusion/hematomas in patients with spontaneous intracranial hypotension (SIH).

MATERIALS AND METHODS

Eight patients were treated under clinical diagnoses of SIH. Chronologic MR imaging studies, including the FLAIR sequence, were retrospectively reviewed.

RESULTS

Initial MR imaging showed diffuse pachymeningeal thickening as isointense in 6 cases, hypoisointense in 1 case, and isohyperintense in 1 case on the T1-weighted MR images, and hyperintense in all cases on both T2-weighted and FLAIR MR images. Dural (pachymeningeal) hyperintensity on FLAIR MR imaging had the highest contrast to CSF, and was observed as linear in all patients, usually located in the supratentorial convexity and also parallel to the falx, the dura of the posterior fossa convexity, and the tentorium, and improved after treatment. These characteristics of diffuse pachymeningeal hyperintensity on FLAIR MR imaging were similar to diffuse pachymeningeal enhancement (DPME) on T1-weighted imaging with gadolinium. Initial FLAIR imaging clearly showed subdural effusion/hematomas in 6 of 8 patients. The thickness of subdural effusion/hematomas sometimes increased transiently after successful treatment and resolution of clinical symptoms.

CONCLUSION

Diffuse pachymeningeal hyperintensity on FLAIR MR imaging is a similar sign to DPME for the diagnosis of SIH but does not require injection of contrast medium. FLAIR is useful sequence for the detection of subdural effusion/hematomas in patients with SIH.

Cerebral venous thrombosis caused by spontaneous intracranial hypotension: two cases

The association of spontaneous intracranial hypotension (SIH) with cerebral venous thrombosis (CVT) is rare. We are reporting two new cases. In one case, CVT is extensive concerning three sinuses and bilateral parietal cortical veins and, in the other case, only a cortical vein is involved. Both the patients presented had no thrombosis risk factors. There is certainly a link between these two pathologies. SIH should be considered as a risk factor of CVT. Modification of symptoms of SIH leading to CVT must be known to start early treatment.