Chronic cerebellar hemorrhage in spontaneous intracranial hypotension: association with ventral spinal cerebrospinal fluid leaks

Pseudohypoxic brain swelling and secondary hydrocephalus with pseudomeningocele after lumbar surgery: a case report

BACKGROUND

Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures.

CASE PRESENTATION

A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly.

CONCLUSIONS

PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.

Surgical closure of spinal cerebrospinal fluid leaks improves symptoms in patients with superficial siderosis

BACKGROUND AND PURPOSE

Spinal cerebrospinal fluid (CSF) leaks may cause a myriad of symptoms, most common being orthostatic headache. In addition, ventral spinal CSF leaks are a possible etiology of superficial siderosis (SS), a rare condition characterized by hemosiderin deposits in the central nervous system (CNS). The classical presentation of SS involves ataxia, bilateral hearing loss, and myelopathy. Unfortunately, treatment options are scarce. This study was undertaken to evaluate whether microsurgical closure of CSF leaks can prevent further clinical deterioration or improve symptoms of SS.

METHODS

This cohort study was conducted using data from a prospectively maintained database in two large spontaneous intracranial hypotension (SIH) referral centers in Germany and Switzerland of patients who meet the modified International Classification of Headache Disorders, 3rd edition criteria for SIH. Patients with spinal CSF leaks were screened for the presence of idiopathic infratentorial symmetric SS of the CNS.

RESULTS

Twelve patients were included. The median latency between the onset of orthostatic headaches and symptoms attributed to SS was 9.5 years. After surgical closure of the underlying spinal CSF leak, symptoms attributed to SS improved in seven patients and remained stable in three. Patients who presented within 1 year after the onset of SS symptoms improved, but those who presented in 8-12 years did not improve. We could show a significant association between patients with spinal longitudinal extrathecal collections and SS.

CONCLUSIONS

Long-standing untreated ventral spinal CSF leaks can lead to SS of the CNS, and microsurgical sealing of spinal CSF leaks might stop progression and improve symptoms in patients with SS in a time-dependent manner.

Likelihood of Discovering a CSF Leak Based on Intracranial MRI Findings in Patients without a Spinal Longitudinal Extradural Collection: A New Probabilistic Scoring System

BACKGROUND AND PURPOSE

The likelihood of discovering a CSF leak can be determined by assessing intracranial abnormalities. However, the Dobrocky scoring system, which is used to determine this likelihood, did not incorporate patients with CSF-venous fistulas. This study sought to create a new probabilistic scoring system applicable to patients without a spinal longitudinal extradural collection.

MATERIALS AND METHODS

A retrospective review was completed of patients with suspected spontaneous intracranial hypotension who underwent brain MR imaging followed by digital subtraction myelography with same-day CT myelography. Patients with and without leaks found on digital subtraction myelography were included. MRIs were assessed for numerous reported stigmata of spontaneous intracranial hypotension and were compared between cohorts.

RESULTS

One hundred seventy-four patients were included; 113 (64.9%) were women (average age, 52.0 [SD, 14.3] years). A CSF leak was found in 98 (56.3%) patients, nearly all of which (93.9%) were CSF-venous fistulas. Diffuse dural enhancement, internal auditory canals dural enhancement, non-Chiari cerebellar descent, pituitary engorgement, brain sag, dural venous sinus engorgement, and decreased suprasellar cistern size were associated with a CSF leak. A probabilistic scoring system was made in which a single point value was assigned to each of those findings: 0-2 considered low probability and ≥3 considered intermediate-to-high probability of a CSF leak.

CONCLUSIONS

This study offers a new probabilistic scoring system for evaluating the likelihood of discovering a CSF leak on the basis of intracranial MR imaging findings, though the new system is not superior to that of the Dobrocky method for predicting the presence of CSF leaks.

Cerebellar Tonsillar Descent Mimicking Chiari Malformation

Chiari I malformation has been defined as cerebellar tonsillar descent greater than 5 mm below the foramen magnum. Suboccipital decompression remains the mainstay of treatment for symptomatic patients. Other conditions sometimes have imaging features that mimic Chiari I malformation. These patients are at risk of misdiagnosis and mismanagement, including surgery that may be unnecessary or may even worsen the underlying condition. The aim of this study was to analyse a series of Chiari I malformation mimics and identify differentiating imaging features. The mimics are categorised as post-traumatic cranio-cervical junction arachnoiditis, dural band, spontaneous intracranial hypotension, idiopathic intracranial hypertension, and cysts. Better understanding of these conditions will assist with diagnosis and optimal management, including avoiding unnecessary surgery.

Infratentorial Superficial Siderosis and Spontaneous Intracranial Hypotension

OBJECTIVE

Spontaneous spinal cerebrospinal fluid (CSF) leaks cause intracranial hypotension (SIH) and also may cause infratentorial superficial siderosis (iSS) but the rate of development among different CSF leak types and outcome of treatment are not known. We determined the time interval from SIH onset to iSS and the outcome of treatment.

METHODS

A total of 1,589 patients with SIH underwent neuroimaging and iSS was detected in 57 (23 men and 34 women, mean age = 41.3 years [3.6%]). We examined the type of underlying CSF leak by various imaging modalities. Percutaneous and surgical procedures were used to treat the CSF leaks.

RESULTS

The iSS was detected in 46 (10.3%) of 447 patients with ventral CSF leaks, in 2 (3.9%) of 51 patients with dural ectasia, in 5 (2.6%) of 194 patients with CSF-venous fistulas, in 4 (0.9%) of 457 patients with simple meningeal diverticula, and in none of the 101 patients with lateral CSF leaks or the 339 patients with leaks of indeterminate origin (p < 0.001). The estimated median latency period from SIH onset to iSS was 126 months. Ventral CSF leaks could not be eliminated with percutaneous procedures in any patient and surgical repair was associated with low risk (<5%) and resulted in resolution of the CSF leak in all patients in whom the exact site of the CSF leak could be determined. Other types of CSF leak were treated with percutaneous or surgical procedures.

INTERPRETATION

The iSS can develop in most types of spinal CSF leak, including CSF-venous fistulas, but mainly in chronic ventral CSF leaks, which require surgical repair. ANN NEUROL 2023;93:64-75.

Progressive superficial siderosis from Chronic CSF leak as a long-term complication of cervical anterior corpectomy: A case report and review of the literature

Background:

Superficial siderosis of the central nervous system (SSCNS) is a rare progressive neurological disorder resulting from chronic subarachnoid hemorrhage and subsequent subpial hemosiderin deposition. A prolonged cerebrospinal fluid (CSF) leak is a known cause of SSCNS. We present a novel case where progressive SSCNS resulted from a chronic CSF leak related to an anterior cervical corpectomy.

Case Description:

A 73-year-old man presented with gait ataxia and progressive hearing loss. Thirteen years before, he had undergone a combined anterior-posterior cervical decompression for symptomatic ossification of the posterior longitudinal ligament (OPLL). The presenting MR imaging showed extensive superficial siderosis and focal spinal cord herniation at the site of a ventral dural defect at the corpectomy site. A CT myelogram showed extensive CSF leakage into the corpectomy surgical site and a communicating pseudomeningocele in the anterior neck.

Conclusion:

This is the first reported case of progressive SSCNS as a long-term complication of an anterior cervical corpectomy for OPLL. Clinicians should be aware of SSCNS secondary to a chronic CSF leak in patients with a prior corpectomy.

Classical infratentorial superficial siderosis of the central nervous system: pathophysiology, clinical features and management

The term superficial siderosis (SS) is derived from the Greek word 'sideros', meaning iron. It includes two subtypes, distinguished by their anatomical distribution, causes and clinical features: 'classical' infratentorial SS (iSS, which sometimes also affects supratentorial regions) and cortical SS (cSS, which affects only supratentorial regions). This paper considers iSS, a potentially disabling disorder usually associated with very slow persistent or intermittent subarachnoid bleeding from a dural defect, and characterised by progressive hearing and vestibular impairment, ataxia, myelopathy and cognitive dysfunction. The causal dural defect-most often spinal but sometimes in the posterior fossa-typically follows trauma or neurosurgery occurring decades before diagnosis. Increasing recognition of iSS with paramagnetic-sensitive MRI is leading to an unmet clinical need. Given the diagnostic challenges and complex neurological impairments in iSS, we have developed a multidisciplinary approach involving key teams. We discuss pathophysiology, diagnosis and management of iSS, including a proposed clinical care pathway.

Diagnostic approach, therapeutic strategies, and surgical indications in intradural thoracic disc herniation associated with CSF leak, intracranial hypotension, and CNS superficial siderosis

Background and purpose

Intradural disc herniation (IDH) can manifest with radicular or medullary syndrome. In about 15% of cases, IDH may be responsible, through a dural laceration, for a CSF leak, determining spontaneous intracranial hypotension (SIH) and CNS superficial siderosis (CNSss). This paper attempts to present an overview on IDH as the cause for both CSF leak, and subsequent SIH, and CNSss, and to describe a peculiar clinical and neuroradiological scenario related to this condition.

Methods

A search on the PUBMED database was performed. Although the investigation did not rigorously follow the criteria for a systematic review (we consider only articles about thoracic IDH), nonetheless, the best quality evidence was pursued. Furthermore, an illustrative case was presented.

Results

A 69-year-old woman was referred to our hospital for slowly progressive gait disturbances and hearing impairment. Brain imaging revealed diffuse bilateral supratentorial and infratentorial superficial siderosis, mostly of the cerebellum, the eighth cranial nerves, and the brainstem. Spinal imaging disclosed a posterior disc herniation determining a dural tear at D6-D7. Lumbar puncture revealed low opening pressure and hemorrhagic CSF with siderophages. A posterior transdural herniectomy and dural sealing determined a stabilization of hearing and a significant improvement in both gait and balance.

Conclusions

The diagnostic workup of CNSss with suspected CNS leak demands whole neuraxis imaging, especially in cases presenting SIH or myelopathic symptoms. This may avoid delays in detection of IDH and spinal dural leaks. The different forms of treatment available depend on the type and severity of the clinical picture.

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

Long-term Risks of Persistent Ventral Spinal CSF Leaks in SIH: Superficial Siderosis and Bibrachial Amyotrophy

BACKGROUND AND OBJECTIVES

Superficial siderosis, bibrachial amyotrophy, and spinal cord herniation are unusual but serious long-term sequelae of persistent spontaneous spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH), particularly ventral spinal CSF leaks. However, the risk of developing such sequelae has not been established in this population. We undertook this study to determine the risk of these serious complications of persistent ventral spinal CSF leaks.

METHODS

This cohort study was conducted using data from a prospectively maintained database of patients who meet the modified International Classification of Headache Disorders, 3rd edition criteria for SIH. The patient population consisted of a consecutive group of patients with SIH and persistent ventral spinal CSF leaks who were first seen within 1 year of onset of SIH symptoms and who had at least 1 year of follow-up.

RESULTS

Among 51 patients with SIH and a persistent ventral spinal CSF leak, superficial siderosis developed in 6 patients and bibrachial amyotrophy in 2 patients during 280 patient-years of follow-up. The probability of these complications increased from 0% at 48 months to 4.5% (95% confidence interval [CI] 1.0%-28.0%) at 56 months, 10.5% (95% CI 3.0%-36.4%) at 96 months, 32.7% (95% CI 15.0%-62.8%) at 144 months, and 57.9% (95% CI 30.2%-87.6%) at 192 months. None of the patients developed spinal cord herniation.

DISCUSSION

Among patients with SIH and a persistent ventral spinal CSF leak, the risk of developing serious long-term sequelae is considerable. This study shows that early treatment of a ventral spinal CSF leak offers a unique opportunity to prevent neurologic disability from superficial siderosis and bibrachial amyotrophy.

Superficial Siderosis: A Clinical Review

Superficial siderosis of the central nervous system results from subpial hemosiderin deposition due to chronic low-grade bleeding into the subarachnoid space. The confluent and marginal subpial hemosiderin is best appreciated on iron-sensitive magnetic resonance imaging sequences. With widespread use of magnetic resonance imaging, the disorder is increasingly being recognized, including in asymptomatic individuals. Gait ataxia, often with hearing impairment is a common clinical presentation. A clinical history of subarachnoid hemorrhage is generally not present. A macrovascular pathology is generally not causative. The most common etiology is dural disease, often dural tears. Prior or less commonly ongoing symptoms of craniospinal hypovolemia may be present. Common etiologies for dural tears include disc disease and trauma, including surgical trauma. Patients with dural tears due to herniated and calcified discs often have a ventral intraspinal fluid collection due to cerebrospinal fluid leak. A precise identification of the dural tear relies on multimodality imaging. It has been speculated that chronic bleeding from fragile blood vessels around the dural tear may be the likely underlying mechanism. Surgical correction of the bleeding source is a logical therapeutic strategy. Clinical outcomes are variable, although neuroimaging evidence of successful dural tear repair is noted. The currently available data regarding use of deferiprone in patients with superficial siderosis is insufficient to recommend its routine use in patients. ANN NEUROL 2021;89:1068-1079.

Diskogenic Dural Defect Is the Reason for the Ventral Location of the Epidural Spinal Fluid Collection Seen in Superficial Siderosis

Purpose of Review

Superficial siderosis (SS) of the nervous system is often due to a dural pathology. This review focuses on recent developments related to the management of this subgroup of patients with SS.

Recent Findings

The presence of an epidural ventral spinal fluid collection in patients with SS is a clue to the presence of a diskogenic dural defect. The location of the defect is ascertained by a dynamic CT myelogram, which involves placing the patient in a prone position with hips elevated. This permits gravity-assisted preferential ventral localization of the contrast and active scanning during contrast injection facilitates a precise delineation of the initial point of contrast extravasation which localizes the defect.

Summary

Diskogenic dural defects are commonly the underlying etiology for SS in patients with a ventral spinal fluid collection. A dynamic CT myelogram facilitates detection and subsequent repair of these defects, which arrests the continued low-grade subarachnoid bleeding.

Superficial siderosis of the central nervous system associated with ventral dural defects: bleeding from the epidural venous plexus

OBJECTIVE

Superficial siderosis of the central nervous system is a rare intractable disease induced by chronic subarachnoid hemorrhage. Neurological deficits, such as cerebellar ataxia and hearing difficulties, gradually progress if left undiagnosed. Hemosiderin deposition is irreversible because standard medical treatment has not yet been established. Interventions at the source of bleeding may be the key to a preferable outcome of treatment for chronic subarachnoid hemorrhage; however, the source is not clear in many cases.

METHODS

Among the consecutive cases diagnosed with a spontaneous cerebrospinal fluid (CSF) leak, cases of superficial siderosis associated with a CSF leak due to a ventral dural defect were retrospectively analyzed.

RESULTS

Among 77 cases of a CSF leak, 7 cases (9%) of superficial siderosis were identified (median age of 59 years, male, 4 cases). Defects were diagnosed on 1-mm sliced fast imaging employing steady-state acquisition MRI (n = 5), conventional myelographic CT (n = 1), or dynamic myelographic CT (n = 1) at high thoracic levels (T1-T4). All defects were repaired by direct neurosurgery. During surgery, continuous bleeding from the epidural veins of the internal vertebral venous plexus was identified as the source of subarachnoid hemorrhage. Epidural CSF pulsations through the defect prevented clot formation by the epidural veins. Dural repair stopped free communication between the subarachnoid and epidural spaces, leading to the disappearance of chronic subarachnoid hemorrhage.

CONCLUSION

Bleeding from the epidural venous plexus may be the cause of superficial siderosis associated with ventral dural defects. Neurosurgical repair may stop the progression of this condition.

Delayed recurrence of spontaneous intracranial hypotension syndrome mimicking a Chiari I malformation: Case report with a review of the literature

INTRODUCTION

Cerebellar tonsils descent seen on brain MRI is, along with other findings, a recognized radiological sign of possible spontaneous intracranial hypotension (SIH). The short-term outcome of SIH is usually favorable with symptoms improvement and reversibility of the low-lying tonsils. Nevertheless, data on the long-term outcome are lacking or inconsistent.

CASE REPORT

A 32-year-old woman presented to her general practitioner with a six months history of non-specific headaches. An MRI brain with gadolinium showed a 12mm tonsillar descent with no other remarkable findings. Headaches were initially managed conservatively as migraines. Following the onset of progressive upper back and shoulder pain at rest, nausea, photophobia and fogging in her vision, the patient was referred to our Department with a suspicion of symptomatic Chiari I malformation. After an in-depth anamnesis, it emerged a previous history of SIH, 14 years earlier, successfully treated conservatively in another center. A whole spine MRI confirmed the suspicion of recurrent SIH showing an anterior cervico-thoracic epidural fluid collection. The patient underwent an epidural blood patch with complete resolution of the symptoms and radiological signs.

DISCUSSION

To our knowledge, this case is the first report of delayed recurrence of a SIH successfully treated conservatively over 10 years earlier. The etiopathogenesis and management of this rarity with literature review is discussed.

CONCLUSION

An isolated cerebellar tonsil descent with no other remarkable findings on brain MRI and a previous history of SIH should always alert the clinician of a possible late recurrence of a CSF leak and avoid unnecessary Chiari I malformation surgical procedures.

Successful endoscopic identification of the bleeding source in the ventral dura of the cervical spine in a case of superficial siderosis

The authors report on the case of a 65-year-old man suffering progressive gait disturbance and hearing impairment due to superficial siderosis (SS). According to the literature, repeated hemorrhage into the subarachnoid space causes SS; however, the bleeding source remains unknown in half of SS patients. In the presented case, preoperative MRI revealed a fluid-filled intraspinal cavity extending from C2 to T8 with a dural defect at the ventral C7 level. During surgery, the dural defect was seen to connect to the intraspinal cavity filled with xanthochromic fluid. Importantly, endoscopic observation verified that the rupture of fragile bridging veins in the cavity was the definite bleeding source. Postoperative MRI confirmed disappearance of the intraspinal cavity, and the patient's symptoms gradually improved. The use of endoscopy helped to establish the diagnosis and led to definite treatment. Fragile bridging veins in the fluid-filled interdural layers were novelly verified as a bleeding source in SS. Recognizing this phenomenon is important since it can establish closure of the dural defect as a definite treatment in SS with an intraspinal cavity.

Ventral Longitudinal Intraspinal Fluid Collection in Patients with Cervical Disc Herniation: A Report of Two Cases

We encountered two cases of cervical disc herniation, wherein cerebrospinal fluid collection in the ventral epidural space between the cervical spine and the thoracic spine was noted. The patients, two women aged 71 and 43 years, were diagnosed with cervical disc herniation and underwent anterior cervical discectomy and fusion. Unexpected cerebrospinal fluid leakage was observed prior to exposure of the dura mater. Notably, the dura mater was intact following the removal of the herniated disc in both cases. No cerebrospinal fluid leakage symptoms were observed, and relief from the neurological symptoms related to the cervical disc herniation was observed in both cases following the surgery. Findings of preoperative magnetic resonance imaging and computed tomography myelography were carefully reviewed, retrospectively. Both patients presented with similar features including expansion of cerebrospinal fluid collection in the ventral epidural space between the cervical spine and the thoracic spine. These observed features were similar to those of superficial siderosis, which is a form of duropathy—a disease caused by dural defects. Therefore, the patients in this case study might have a subclinical duropathy with associated cervical disc herniation.

Postoperative Cerebrospinal Fluid Leak After Lumbar Total Disc Replacement: A Diagnostic and Management Challenge

BACKGROUND

Lumbar total disc replacement is increasingly becoming a more common treatment for discogenic low back pain refractory to conservative measures. Nevertheless, several complications have been reported, including, among others, wound infection, vascular injury, retrograde ejaculation, postsympathectomy syndrome, ileus, and cerebrospinal fluid (CSF) leak. Although CSF leakage is rare, we discuss a case of CSF leakage and the diagnosis and management of CSF leakage after lumbar total disc replacement.

CASE DESCRIPTION

A 25-year-old man had presented with discogenic low back pain caused by degenerative disc disease of 9 years' duration. His symptoms were exacerbated by activity, worse with sitting, and relieved by ice baths. He developed a cerebrospinal fluid leak after L5-S1 lumbar total disc replacement.

CONCLUSIONS

Our patient ultimately required device removal, direct repair, and replacement with a different prosthesis to treat his CSF leak.

Spontaneous spinal CSF-venous fistulas associated with venous/venolymphatic vascular malformations: report of 3 cases

Spontaneous CSF-venous fistulas may be present in up to one-fourth of patients with spontaneous intracranial hypotension. This is a recently discovered type of CSF leak, and much remains unknown about these fistulas. Spinal CSF-venous fistulas are usually seen in coexistence with a spinal meningeal diverticulum, suggesting the presence of an underlying structural dural weakness at the proximal portion of the fistula. The authors now report the presence of soft-tissue venous/venolymphatic malformations associated with spontaneous spinal CSF-venous fistulas in 2 patients with spontaneous intracranial hypotension, suggesting a role for distal venous pathology. In a third patient with spontaneous intracranial hypotension and a venolymphatic malformation, such a CSF-venous fistula is strongly suspected.

Widening the spectrum of secondary headache: intracranial hypotension following a non-aneurysmal subarachnoid hemorrhage

BACKGROUND

Intracranial hypotension has been associated with a wide spectrum of neurological conditions including chronic non-aneurysmal and acute aneurysmal subarachnoid hemorrhage.

CASE

A 59-year-old man presented with a non-aneurysmal subarachnoid hemorrhage in a perimesencephalic pattern after a mild physical exertion. In the course of the disease, a magnetic resonance imaging of head and spine displayed intracranial hypotension that resolved spontaneously.

DISCUSSION

Long-standing intracranial hypotension has been reported as the cause of chronic subarachnoid hemorrhage and a single case of intracranial hypotension as the consequence of intracranial pressure fluctuations after acute aneurysmal subarachnoid hemorrhage has been described. This is the first description of intracranial hypotension caused by acute non-aneurysmal subarachnoid hemorrhage. We hypothesize that blood in the subarachnoid space could have determined a spine cerebrospinal fluid leak through intracranial pressure fluctuations or mechanical action, causing arachnoiditis and possibly a dural tear.

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.

Superficial siderosis of the central nervous system associated with intraspinal hemorrhage from ventral thoracic epidural veins and a ventral spinal CSF leak: case report

In most patients with superficial siderosis of the CNS, the exact source of bleeding remains unknown because of a lack of objective surgical data. The authors herein describe the case of a 58-year-old man with superficial siderosis of the CNS. The patient also had spinal CSF leakage due to a spinal dural defect. Repair surgery for the dural defect was performed using posterior laminoplasty with a transdural approach without spinal fixation. During repair surgery, the bleeding source was found to be the epidural vein around the defect. The intraoperative and histological results of the present case suggest that epidural veins exposed to CSF represent a chronic bleeding source in patients with superficial siderosis of the CNS complicated by CSF leakage. Dural repair surgery may result in discontinuation of the CSF leaks, resolution of the epidural CSF collection, and cessation of chronic epidural bleeding.

Digital subtraction myelography in the investigation of post–dural puncture headache in 27 patients: technical note

OBJECTIVE

Post–dural puncture headaches are common, and the treatment of such headaches can be complex when they become chronic. Among patients with spontaneous spinal CSF leaks, digital subtraction myelography (DSM) can localize the exact site of the leak when an extradural CSF collection is present, and it can also demonstrate CSF-venous fistulas in those without an extradural CSF collection. The authors now report on the use of DSM in the management of patients with chronic post–dural puncture headaches.

METHODS

The patient population consisted of a consecutive group of 27 patients with recalcitrant post–dural puncture headache that had lasted from 2 to 150 months (mean 26 months).

RESULTS

The mean age of the 17 women and 10 men was 39.1 years (range 18–77 years). An extensive extradural CSF collection was present in 5 of the 27 patients, and DSM was able to localize the exact site of the dural defect in all 5 patients. Among the 22 patients who did not have an extradural CSF collection, DSM showed a CSF-venous fistula in 1 patient (5%). Three other patients had a small pseudomeningocele at the level of the dural puncture. Percutaneous glue injection or microsurgical repair resulted in resolution of symptoms in 8 of the 9 patients in whom an abnormality had been identified on imaging.

CONCLUSIONS

Digital subtraction myelography is able to precisely localize the dural puncture site in patients with a post–dural puncture headache and an extensive extradural CSF collection, and it may rarely detect a CSF-venous fistula in such patients without an extradural CSF collection.

Vanishing calcification associated with a spontaneous ventral spinal cerebrospinal fluid leak

Background

Some patients with spontaneous intracranial hypotension have a ventral spinal cerebrospinal fluid (CSF) leak and these CSF leaks may be associated with calcified disk herniations. Identifying these calcifications is helpful in directing treatment. We report here the unusual case of a patient with a ventral CSF leak in whom the associated calcification absorbed over a five-month period.

Case report

A 42-year-old woman developed orthostatic headaches and bilateral abducens nerve palsies. Magnetic resonance imaging of her brain showed typical findings of spontaneous intracranial hypotension. Magnetic resonance imaging of her spine showed an extensive cervicothoracic CSF leak. Computed tomographic myelography showed calcification at the Th1–2 disk space. Three epidural blood patches were performed, but her symptoms persisted. Digital subtraction myelography performed five months later showed an upper thoracic ventral CSF, but the calcification was no longer present. A dural tear, found at surgery at the Th1–2 level, was repaired and the patient made an uneventful recovery.

Discussion

The resorption of calcifications at the level of a ventral spinal CSF leak could explain the absence of any calcifications in at least some patients with such leaks and demonstrates the usefulness of reviewing previous imaging in patients with ventral CSF leaks if the exact site of the leak remains unknown.

CT Fluoroscopy-Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach

BACKGROUND AND PURPOSE

Epidural blood patch treatment of spontaneous intracranial hypotension arising from ventral CSF leaks can be difficult secondary to challenges in achieving ventral spread of patching material. The purpose of this study was to determine the technical success rates and safety profile of direct needle placement into the ventral epidural space via a posterior transforaminal approach.

MATERIALS AND METHODS

We retrospectively reviewed consecutive CT fluoroscopy-guided epidural blood patches from June 2013 through July 2015. Cases were included if a posterior transforaminal approach was taken to place the needle directly in the ventral epidural space. Rates of technical success (defined as contrast in the spinal canal ventral epidural space) and optimal epidurogram (defined as contrast spreading into or beyond the middle third of the spinal canal ventral epidural space) were determined. Factors influencing these rates were assessed. All complications, inadvertent intravascular injections, and intrathecal punctures were recorded.

RESULTS

A total of 72 ventral epidural blood patches were identified; immediate technical success was achieved in 95.8% and an optimal epidurogram in 47.2%. Needle position within the spinal canal ventral epidural space was associated with obtaining an optimal epidurogram (P = .005). Inadvertent intravascular injection was identified in 29.3% of cases, but all were venous. There were no inadvertent intrathecal punctures or complications.

CONCLUSIONS

Direct needle placement in the ventral epidural space via a transforaminal approach for treatment of ventral CSF leaks has an excellent technical success rate and safety profile. This technique can be considered as a treatment option in selected patients with ventral CSF leaks for whom traditional techniques are unsuccessful.

Intraspinal hemorrhage in spontaneous intracranial hypotension: link to superficial siderosis? Report of 2 cases

Spontaneous intracranial hypotension due to a spinal CSF leak has become a well-recognized cause of headaches, but such spinal CSF leaks also are found in approximately half of patients with superficial siderosis of the CNS. It has been hypothesized that friable vessels at the site of the spinal CSF leak are the likely source of chronic bleeding in these patients, but such an intraspinal hemorrhage has never been visualized. The authors report on 2 patients with spontaneous intracranial hypotension and intraspinal hemorrhage, offering support for this hypothesis. A 33-year-old man and a 62-year-old woman with spontaneous intracranial hypotension were found to have a hemorrhage within the ventral spinal CSF collection and within the thecal sac, respectively. Treatment consisted of microsurgical repair of a ventral dural tear in the first patient and epidural blood patching in the second patient. The authors suggest that spontaneous intracranial hypotension should be included in the differential diagnosis of spontaneous intraspinal hemorrhage, and that the intraspinal hemorrhage can account for the finding of superficial siderosis when the CSF leak remains untreated.

Repair of a traumatic subarachnoid-pleural fistula with the percutaneous injection of fibrin glue in a 2-year-old

Subarachnoid-pleural fistulas (SPFs) are rare clinical entities that occur after severe thoracic trauma or iatrogenic injury during anterolateral approaches to the spine. Treatment of these fistulas often entails open repair of the dural defect. The authors present the case of an SPF in a 2-year-old female after a penetrating injury to the chest. The diagnosis of an SPF was suspected given the high chest tube output and was confirmed with a positive β2-transferrin test of the chest tube fluid, as well as visualization of dural defects on MRI. The dural defects were successfully repaired with CT-guided percutaneous epidural injection of fibrin glue alone. This case represents the youngest pediatric patient with a traumatic SPF to be treated percutaneously. This technique can be safely used in pediatric patients, offers several advantages over open surgical repair, and could be considered as an alternative first-line therapy for the obliteration of SPFs.

Diffuse non-aneurysmal SAH in spontaneous intracranial hypotension: Sequela of ventral CSF leak?

Background

Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak has become a well-recognized cause of headaches. Recently, various unusual neurological syndromes have been described in such patients with chronic ventral CSF leaks, including superficial siderosis and an amyotrophic lateral sclerosis-like syndrome. The authors now report two patients with spontaneous intracranial hypotension due to a chronic ventral CSF leak who suffered a diffuse non-aneurysmal subarachnoid hemorrhage (SAH).

Description of cases

A 62-year-old woman underwent uneventful microsurgical repair of a ventral thoracic CSF leak that had been present for 13 years. Seventeen months after surgery, she was found unresponsive and CT showed a diffuse intracranial SAH. Cerebral angiography and spine and brain MRI did not reveal a source of the SAH. A 73-year-old woman was found unresponsive and CT showed a diffuse intracranial SAH. Cerebral angiography and brain MRI did not reveal a source of the SAH, although superficial siderosis was detected. Spine MRI showed a ventral thoracic CSF leak that by history had been present for 41 years. She underwent uneventful microsurgical repair of the CSF leak.

Discussion

The authors suggest that patients with a ventral spinal CSF leak of long duration may be at risk of diffuse non-aneurysmal SAH.

Remote Cerebellar Hemorrhage Complicating Unintended Durotomy in Lumbar Spine Surgery

STUDY DESIGN

Case reports and retrospective review of accidental durotomies in lumbar surgeries during 5 years.

OBJECTIVES

To draw attention to a potentially serious complication of incidental durotomy-remote cerebellar hemorrhage.

SUMMARY AND BACKGROUND DATA

Accidental durotomy is a frequent complication of spinal surgery. In most cases the outcome of incidental durotomy is favorable. A delayed potentially serious complication of CSF loss during and after lumbar surgery is remote cerebellar hemorrhage (RCH).

METHODS

During 2008-2012, 1169 lumbar spine procedures were performed at our spine center. In 210 surgeries incidental or intentional durotomies occurred. All patients with durotomies were managed with suturing of the dural wound followed by deep wound drainage left for 5 days and tight wound closure.

RESULTS

Of the 210 patients with CSF loss three patients were identified to suffer from RCH-an incidence of 0.26%. The three patients ages 56, 67 and 75 years developed RCH between 36-192 hours after surgery. All three were managed with supportive treatment and close clinical supervision. A gradual clinical and radiological improvement was noted in all three patients.

CONCLUSIONS

Severe headache after spinal surgery and or declining mental status should not be attributed only to low CSF pressure secondary to dural tearing. It can also be the result of remote cerebral or cerebellar hemorrhage. Once the diagnosis of RCH is made, close clinical supervision is mandatory. In most cases non-operative supportive treatment may lead to eventual full clinical recovery.

Superficial siderosis: bleeding from the bone marrow after laminectomy for spinal tumor removal

Superficial siderosis of the CNS is a rare disease characterized by the deposition of hemosiderin in the subpial layers of the CNS as the result of chronic subarachnoid bleeding. The arrest of bleeding is important for preventing the progression of this disease; however, the exact source of bleeding remains unknown in most cases because of a lack of objective surgical data. The authors of this report have described a unique case of superficial siderosis following cervical laminectomy and autograft fusion for the removal of a spinal schwannoma; the bleeding source was verified by intraoperative and histopathological findings. The patient exhibited no obvious neurological deficits, such as hearing loss or cerebellar ataxia, when the superficial siderosis was diagnosed, although there were the social impairments associated with schizophrenia. During repair surgery, the bleeding source was revealed as the bone marrow vasculature of the remaining vertebral arch, and not the fragile vessels at the dural defect or the residual tumor. Chronic bleeding was stopped before the onset of irreversible neurological deficits in this case. Bone marrow exposed to the intrathecal space may represent a chronic bleeding source in patients with superficial siderosis following CNS surgery including laminectomy or craniotomy. The following recommendations have been proposed for superficial siderosis of the CNS from both a preventative and a therapeutic perspective: 1) During CNS surgery, neurosurgeons should make every effort to prevent exposing bone marrow to the intrathecal space to avoid the risk of chronic subarachnoid bleeding. 2) In the case of a large dural defect and pseudomeningocele following CNS surgery, bone marrow around the dural defect should be considered as the bleeding source of superficial siderosis, and such cases should undergo revision surgery before the progression of this disease.

Spinal epidural hematoma related to intracranial hypotension

A 45-year-old female patient visited the hospital complaining of severe sudden headache and posterior neck pain. The patient did not have any traumatic history or abnormal neurologic finding. The patient had sudden quadriplegia and sensory loss. Cervical spine MRI scan was taken, and the compatible findings to acute epidural hematoma were shown. The emergency operation was performed. After the operation, the patient recovered all motor and senses. As there was CSF leakage in the postoperative wound, this was confirmed by cervical spinal computed tomography (CT). Then lumbar drainage was thus performed. The opening pressure upon lumbar puncture was not measured as it was very low. As a result of continous CSF leakage, dural repair was performed. After the operation, the patient had been discharged without neurologic deficits. In this case, it is sensible to suspect intracranial hypotension as a possible cause of spinal EDH.

Spinal manifestations of spontaneous intracranial hypotension

Object

The goal of the study was to elucidate the spinal manifestations of spontaneous intracranial hypotension.

Methods

The authors reviewed the medical records and imaging studies of 338 consecutive patients with spontaneous intracranial hypotension who were evaluated at their institution between 2001 and 2010.

Results

Twenty patients (6%; mean age 35.8 [range 16 to 60 years]; 5 males and 15 females) had convincing signs or symptoms referable to the spinal cord or spinal nerve roots. The spinal manifestations consisted of radiculopathy in 11 patients (unilateral in 8 and bilateral in 3), myelopathy in 8 patients, and bibrachial amyotrophy in 1 patient. The cervical spine was involved in 12 patients, the thoracic spine in 5, and the lumbosacral spine in 3. The spinal symptoms were positional in only 3 patients. The spinal manifestations occurred around the time of the headache onset in 16 patients, and months to years after the positional headache had resolved in 4 patients. A large extrathecal CSF collection causing compression of the spinal cord or nerve root was responsible for the spinal manifestations in the majority of patients. Treatment of the spinal CSF leak resulted in resolution of the spinal manifestations along with the headache, except for those in the patient with bibrachial amyotrophy.

Conclusions

Spinal manifestations are uncommon in cases of spontaneous intracranial hypotension, occurring in about 6% of patients, but myelopathy and radiculopathy involving all spinal segments do occur. Unlike the headache, the spinal manifestations usually are not positional and are caused by mass effect from an extradural CSF collection.

Ventral spinal cerebrospinal fluid leak as the cause of persistent post-dural puncture headache in children

Headache occurs after dural puncture in about 1%-25% of children who undergo the procedure-a rate similar to that seen in adults. Persistence of post-dural puncture headache in spite of bed rest, increased fluid intake, and epidural blood patch treatment, however, is rare. The authors reviewed the medical records and imaging studies of all patients 19 years of age or younger who they evaluated between 2001 and 2010 for intracranial hypotension, and they identified 8 children who had persistent post-dural puncture headache despite maximal medical treatment and placement of epidural blood patches. A CSF leak could be demonstrated radiologically and treated surgically in 3 of these patients, and the authors report these 3 cases. The patients were 2 girls (ages 14 and 16 years) who had undergone lumbar puncture for evaluation of headache and fever and 1 boy (age 13 years) who had undergone placement of a lumboperitoneal shunt using a Tuohy needle for treatment of pseudotumor cerebri. The boy also had undergone a laminectomy and exploration of the posterior dural sac, but no CSF leak could be identified. All 3 patients presented with new-onset orthostatic headaches, and in all 3 cases MRI demonstrated a large ventral lumbar or thoracolumbar CSF collection. Conventional myelography or digital subtraction myelography revealed a ventral dural defect at L2-3 requiring surgical repair. Through a posterior transdural approach, the dural defect was repaired using 6-0 Prolene sutures and a dural substitute. Postoperative recovery was uneventful, with complete resolution of orthostatic headache and of the ventral cerebrospinal fluid leak on MRI. The authors conclude that persistent postdural puncture headache requiring surgical repair is rare in children. They note that the CSF leak may be located ventrally and may require conventional or digital subtraction myelography for exact localization and that transdural repair is safe and effective in eliminating the headaches.