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Kim YS, Joo SP, Ahn KH, Kim TS. Spontaneous intracranial hypotension presenting with bilateral subdural hematoma: Decision-making and treatment strategies. J Clin Neurosci 2024; 121:77-82. [PMID: 38367404 DOI: 10.1016/j.jocn.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/30/2023] [Accepted: 02/08/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The timing and decision to drain subdural hematoma (SDH) in spontaneous intracranial hypotension (SIH) remains a dilemma. We reviewed our experience of bilateral SDH secondary to SIH, focusing on decision making and treatment strategies. METHODS We retrospectively reviewed bilateral SDH secondary to SIH between March 2010 and September 2021. Baseline characteristics of patients, diagnosis, radiologic findings, treatments, and clinical outcome were investigated. RESULTS Fifteen patients (7 men, 8 women) with bilateral SDH secondary to SIH were included in this study. Initially, patients were treated conservatively (4 patients, 26.7 %), with an epidural blood patch (EBP, 3 patients, 20.0 %), and SDH drainage followed by the Trendelenburg position (8 patients, 53.3 %). All 3 patients that were initially treated with EBP required SDH drainage. Of the 8 patients initially treated with SDH drainage via burr hole followed by Trendelenburg position, 7 patients showed sustained improvements without EBP; however, 1 patient needed EBP. Deterioration to coma occurred in 6 out of 15 patients (40.0 %). All 6 deteriorated patients immediately recovered after SDH drainage with Trendelenburg position; 5 achieved sustained improvement without EBP and 1 required EBP. During the follow-up period, 14 out of 15 patients (93.3 %) showed good recovery. CONCLUSIONS Evacuation of SDH is not always necessary in SIH; however, we did not hesitate to perform hematoma drainage, in deteriorated patients or those with thick hematoma that is associated with significant sagging and cistern effacement. This can prevent irreversible neurologic complications. Moreover, the Trendelenburg position may help to achieve sustained improvement without additional treatment.
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Affiliation(s)
- You-Sub Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.
| | - Kang-Hee Ahn
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
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Baram A, Zaed I, Safa A, Robertis MD, Lasio G, Maira G, Cannizzaro D. Intracranial Hypotension Syndrome after Lumbar Drainage in Skull Base Surgery: Diagnosis and Correct Management. J Neurol Surg A Cent Eur Neurosurg 2023; 84:578-583. [PMID: 37263292 DOI: 10.1055/s-0042-1759825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Lumbar drainage is commonly used in skull base surgery; however, very few cases of intracranial hypotension syndrome are reported to be caused by this procedure. We present a clinical case of lumbar drainage-assisted orbital and optic canal decompression surgery for a recurrent voluminous spheno-orbital meningioma, together with a literature review. A 49-year-old woman became confused and drowsy on postoperative day 3, after initially experiencing neurologic stability. Computed tomography (CT) scan of the head showed extradural frontotemporal fluid collection with moderate right to left midline shift. Magnetic resonance imaging (MRI) of the brain showed signs of intracranial hypotension, such as brain sagging and diffuse dural contrast enhancement. Conservative treatment with bed rest, aggressive hydration, steroids, and aminophylline led to progressive neurologic improvement. A systematic literature review was also performed, and previous reported cases were analyzed. Overall, neurosurgeons must be aware of the lumbar drainage-induced hypotension syndrome in skull base surgeries, because immediate diagnosis is essential for therapeutic decision-making. In this setting, conservative management is the first-line treatment as surgery may lead to severe complications.
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Affiliation(s)
- Ali Baram
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Ismail Zaed
- Division of Neurosurgery, ASST Ovest Milanese, Legnano Hospital, Milan, Italy
| | - Adrian Safa
- Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | | | - Giovanni Lasio
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Giulio Maira
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Delia Cannizzaro
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
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Lashkarivand A, Eide PK. Brain Sagging Dementia. Curr Neurol Neurosci Rep 2023; 23:593-605. [PMID: 37676440 PMCID: PMC10590313 DOI: 10.1007/s11910-023-01297-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE OF REVIEW Brain sagging dementia (BSD) is a rare but devastating form of early-onset dementia characterized by intracranial hypotension and behavioral changes resembling behavioral variant frontotemporal dementia. This review aims to provide a comprehensive overview of BSD, highlighting its pathomechanism, diagnostic tools, and available treatment options. RECENT FINDINGS BSD exhibits a complex clinical manifestation with insidious onset and gradual progression of behavioral disinhibition, apathy, inertia, and speech alterations. Additionally, patients may exhibit brainstem and cerebellar signs such as hypersomnolence and gait disturbance. Although headaches are common, they may not always demonstrate typical orthostatic features. Recent radiological advances have improved the detection of CSF leaks, enabling targeted treatment and favorable outcomes. Understanding the pathomechanism and available diagnostic tools for BSD is crucial for a systematic approach to timely diagnosis and treatment of this reversible form of early-onset dementia, as patients often endure a complex and lengthy clinical course.
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Affiliation(s)
- Aslan Lashkarivand
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Nydalen, N-0424, Pb 4950, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Nydalen, N-0424, Pb 4950, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Inamasu J, Fujisawa M, Sato M. Spontaneous Intracranial Hypotension Occurring after Craniotomy for Brain Tumor Biopsy Mimicking Postoperative Bleeding. NMC Case Rep J 2023; 10:247-252. [PMID: 37869378 PMCID: PMC10584665 DOI: 10.2176/jns-nmc.2023-0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/21/2023] [Indexed: 10/24/2023] Open
Abstract
In this study, we report on a previously healthy 44-year-old man who underwent an open biopsy under general anesthesia for a tumorous lesion found in his left frontal lobe via a small supratentorial craniotomy. While both postoperative course and brain computed tomography (CT) scans had been considered unremarkable, the patient became stuporous on postoperative day (POD) 4. A brain CT obtained on that day showed a subdural hematoma with marked brain shift which we thought might have been due to postoperative bleeding; he was immediately brought to an operating theater for hematoma removal. However, no bleeding source was found, and the brain remained depressed after hematoma evacuation. Furthermore, the brain shift remained unchanged on postoperative CT. While spontaneous intracranial hypotension (SIH) was considered, imaging studies to search for possible cerebrospinal fluid (CSF) leakage in the spinal column were not performed as the patient's condition has improved. However, he became stuporous again on POD 8, which urged us to perform CT myelogram. The CT myelogram showed a massive CSF leakage at the L1-L2 level. Subsequent autologous blood patch has successfully terminated the CSF leakage, and he became fully oriented shortly after the blood patch therapy. Thus, it should be noted that SIH may occur during postoperative period of intracranial surgery, and it may manifest radiographically as a subdural hematoma indistinguishable from postoperative bleeding. SIH should also be included in a differential diagnosis of postoperative headache, regardless of its characteristics, because headache associated with SIH may not always be orthostatic.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Masashi Fujisawa
- Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
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Brosnan C, Dablouk MO, Healy V, Murray D, Soleiman HA, Bolger C. When does too little pressure become too much? A case of spontaneous intracranial hypotension presenting with acute loss of consciousness. Surg Neurol Int 2023; 14:338. [PMID: 37810301 PMCID: PMC10559507 DOI: 10.25259/sni_293_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/29/2023] [Indexed: 10/10/2023] Open
Abstract
Background We present a unique case of spontaneous intracranial hypotension (SIH) presenting with acute collapse and loss of consciousness. Case Description The affected patient suffered an abrupt decline in level of consciousness several weeks after initial diagnosis. The patient was urgently transferred to a specialist neurosurgical unit. Imaging showed bilateral subdural fluid collections with significant associated local mass effect. The treating team faced a clinical conundrum with a lack of clarity as to whether this sudden deterioration was secondary to the local pressure effect on brainstem traction from reduced intracranial pressure. A decision was made to proceed with urgent burr-hole decompression of the bilateral subdural fluid collections. Conclusion After a protracted, complex postoperative course, the patient recovered to full functional independence. To the author's knowledge, this is the first case in literature describing successful surgical management of SIH, with bilateral burr-hole evacuation to relieve the paradoxical mass effect of bilateral subdural fluid collections.
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Affiliation(s)
- Conor Brosnan
- Department of Radiology, Beaumont Hospital, Dublin 9, Ireland
| | - Mohamed Osman Dablouk
- Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Vincent Healy
- Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Daniel Murray
- Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Hamzah A. Soleiman
- Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Ciaran Bolger
- Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Terakado T, Omi A, Matsumaru Y, Ishikawa E. Two Cases of Chronic Subdural Hematoma with Spontaneous Intracranial Hypotention Treated with Hematoma Drainage Followed by Epidural Blood Patch Under Intracranial Pressure Monitoring. NMC Case Rep J 2023; 10:93-98. [PMID: 37131497 PMCID: PMC10149143 DOI: 10.2176/jns-nmc.2022-0356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/23/2023] [Indexed: 05/04/2023] Open
Abstract
Both chronic subdural hematoma (CSDH) and spontaneous intracranial hypotension (SIH) cause headaches. However, the etiologies are different: SIH headache is caused by decreased intracranial pressure (ICP), whereas CSDH headache results from increased ICP. Moreover, CSDH is treated by hematoma drainage, while SIH is treated by epidural blood patch (EBP). Treatment for the cases of combined SIH and CSDH is not well-established. Herein, we report two cases wherein ICP was monitored and safely controlled by EBP after hematoma drainage. Case 1: A 55-year-old man with progressive consciousness disturbance was diagnosed with bilateral CSDH. He underwent bilateral hematoma drainage; however, the headache became apparent during standing. We diagnosed SIH by diffuse pachymeningeal enhancement on brain MRI and epidural contrast medium leakage on CT myelography. Due to the re-enlargement of bilateral CSDH, we performed EBP after hematoma drainage and ICP monitor insertion. Finally, the headache and bilateral CSDH were resolved. Case 2: A 54-year-old man with persistent headache was diagnosed with bilateral CSDH. He underwent multiple hematoma drainage sessions. However, headache on standing persisted. We diagnosed SIH by diffuse pachymeningeal enhancement on brain MRI and epidural contrast medium leakage on CT myelography. Due to the re-enlargement of the left CSDH, we performed EBP after left hematoma drainage and ICP monitor insertion. Finally, the headache and bilateral CSDH were resolved. EBP after hematoma drainage and ICP monitoring was useful for SIH with bilateral CSDH. By monitoring ICP before EBP, the ICP was safely controlled and CSDH was resolved.
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Affiliation(s)
- Toshitsugu Terakado
- Department of Neurosurgery, Koyama Memorial Hospital, Kashima, Ibaraki, Japan
| | - Akibumi Omi
- Department of Anesthesiology, Koyama Memorial Hospital, Kashima, Ibaraki, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Lasunin NV, Cherekaev VA, Usachev DY, Abdullaev AN, Okishev DN, Pronin IN, Konovalov AN. [Complicated course of the postoperative period with the development of epidural hygroma and intracranial hypotension after removal of cranio-orbital meningioma. Clinical case and literature review]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:94-103. [PMID: 37830474 DOI: 10.17116/neiro20238705194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Surgical removal of cranio-orbital meningiomas is an effective method of treating this pathology. Modern surgical techniques and technologies make it possible to perform operations with a low risk of complications. Lumbar drainage or repeated lumbar punctures are often used intraoperatively or in the early postoperative period to prevent nasal CSF leak; this rarely leads to the development of significant neurological symptoms. We present a case of the development of severe intracranial hypotension with the formation of a subdural hygroma in the early postoperative period after removal of a cranio-orbital meningioma in a 41-year-old patient. The operation was performed using an individual model and molds for simultaneous reconstruction of the bone defect with an implant made of polymethyl methacrylate. On the 1st and 2nd days after surgery, lumbar punctures were performed. From the 2nd day there was a progressive deterioration with the development of symptoms characteristic of intracranial hypotension. Computed tomography revealed an increasing displacement of the midline structures of the brain and an increasing volume of epidural fluid accumulation in the area of surgical intervention. Magnetic resonance imaging revealed characteristic signs of intracranial hypotension. Conservative treatment (bed rest, active hydration) had no effect. On the 6th day after surgery, an epidural blood patch procedure was performed and closed external drainage of the epidural hygroma was performed, and a rapid regression of neurological symptoms was noted. Our experience and literature data indicate that it is necessary to remember the possibility of developing clinically significant intracranial hypotension even after a single lumbar puncture. The formation of hygromas in the surgical area is characteristic of intracranial hypotension, but in most cases does not require additional surgical intervention and does not have a negative impact on the outcome of treatment. Conservative treatment of intracranial hypotension is the first choice and often sufficient. If there is no effect and the patient's condition worsens, it is necessary to perform an epidural blood patch procedure.
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Affiliation(s)
- N V Lasunin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
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Signorelli F, Visocchi M. Spontaneous Intracranial Hypotension: Controversies in Treatment. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:209-211. [PMID: 38153471 DOI: 10.1007/978-3-031-36084-8_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is a disorder of low cerebrospinal fluid (CSF) volume secondary to CSF leakage through a dural defect along the neuraxis with an estimated incidence of 5 people per 100,000.Great debate persists on the optimal treatment of this pathology, and clinical results are often contradictory. SIH may be initially approached via conservative measures, such as bed rest that is often supplemented with hydration, caffeine, and theophylline, which overall relieve symptoms in a small subset of patients at 6 months. Epidural blood patching (EBP) is generally the next consideration in symptom management. It is the most commonly performed intervention for spinal CSF leaks, as the first option or following the failure of conservative treatment. Further procedures may be performed in the case of EBP partial or temporary response and if the spinal CSF leak has been definitively localized (Beck et al., Neurology 87:1220-26, 2016). In those cases, if the CSF leak is well localized, the surgical closure of the spinal CSF leak may be considered.SIH is a complex but treatable CSF disorder. Despite recent advances in the field of neuroimaging and the different therapeutic options available, the appropriate management remains controversial and should be tailored to the patient.
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Affiliation(s)
- Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
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9
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Huang H, Wei TT, Niu ZF, Yu L, He FF. Case report: Epidural blood patches are effective in treating intracranial hypotension due to a subarachnoid-pleural fistula. Front Surg 2022; 9:936949. [PMID: 36238858 PMCID: PMC9551272 DOI: 10.3389/fsurg.2022.936949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background Intracranial hypotension (IH) is usually associated with cerebrospinal fluid (CSF) leakage and/or CSF hypotension, and epidural blood patch (EBP) therapy has been proven to be effective for treating spontaneous IH and post-dural puncture headaches. Tarlov cysts (TCs) are common lesions of the sacral spine. They have rarely been reported in thoracic locations and are even less common in the posterior mediastinum, which can lead to their misdiagnosis as neurogenic tumors. Case presentation Here, we report the case of a 60-year-old woman who developed an orthostatic headache after the thoracoscopic resection of a TC in the posterior mediastinum that was presumed to be a schwannoma preoperatively. The patient was finally diagnosed with IH caused by a subarachnoid-pleural fistula (SPF) and was cured by targeted EBP treatment. Conclusion This is a case to show that a single targeted EBP treatment is effective for a patient with IH caused by an SPF after thoracoscopic resection of a TC. This case reminds us to be vigilant that a TC may be masquerading as a posterior mediastinal neurogenic tumor, and a detailed examination should be performed to identify it before deciding on a surgical procedure. In addition, postural headache after thoracoscopic spinal surgery should be alert to the possibility of IH induced by an SPF. Once it occurs, early treatment is necessary, and targeted EBP treatment can serve as a safe and effective alternative when conservative treatment fails.
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Affiliation(s)
- Hua Huang
- Department of Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ting-Ting Wei
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhong-Feng Niu
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Liang Yu
- Department of Quality Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fei-Fang He
- Department of Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Correspondence: Fei-Fang He
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10
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Eley V, Keita H, Bouvet L. Epidural blood patch - still the best therapy for headaches related to intracranial hypotension. Anaesth Crit Care Pain Med 2022; 41:101139. [PMID: 35926771 DOI: 10.1016/j.accpm.2022.101139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - Hawa Keita
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation pédiatrique, Paris, France; Unité de Recherche EA 7323 Pharmacologie et Évaluation des Thérapeutiques Chez l'Enfant et la Femme Enceinte, Université de Paris, Paris, France
| | - Lionel Bouvet
- Service d'Anesthésie Réanimation, Groupement Hospitalier Est, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France; APCSe VetAgro Sup UP 2021, A101, Lyon, France.
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Zetlaoui PJ, Buchheit T, Benhamou D. Epidural blood patch: A narrative review. Anaesth Crit Care Pain Med 2022; 41:101138. [DOI: 10.1016/j.accpm.2022.101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
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Masourou Z, Papagiannakis N, Mantzikopoulos G, Mitsikostas DD, Theodoraki K. Treating Spontaneous Intracranial Hypotension with an Anesthetic Modality: The Role of the Epidural Blood Patch. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081109. [PMID: 35892911 PMCID: PMC9331680 DOI: 10.3390/life12081109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic and therapeutic challenge; it can present with a broad clinical spectrum of symptoms, can lead to SDH and, if conservative treatment fails, an epidural blood patch (EBP) is a viable treatment option. Although the exact etiology of SIH is not known, it is believed to be due to cerebrospinal fluid (CSF) leak or a low CSF pressure. Case Series: Three patients (two males and one female) with ages ranging between 38 and 53 years old who presented with complaints of not only an orthostatic headache, but also a variety of symptoms of SIH, including the formation of two SDHs in one of them, were included in this series. These patients did not respond to conservative management and, subsequently, given the clinical and radiological evidence of SIH, were referred to the Anesthesiology Department for an EBP. Diagnostic workup was facilitated by imaging modalities, including magnetic resonance imaging (MRI) of the brain and spinal cord, prior to the EBP. All three patients were subjected to an EBP with an 18-gauge epidural needle. A total of between 30 and 43 mL of autologous blood was collected from the patients and was injected into the epidural space under strict aseptic conditions. Two lumbar (L1-L2, L2-L3) EBPs and one thoracic (T11-T12) EBP were performed on the three patients, respectively. All patients reported complete resolution of symptoms following the EBPs, while MRI improved substantially. Conclusions: This report describes three cases of SIH with CSF leak originating from the cervical, the thoracic and the lumbar level. The EBP restored CSF pressure and relieved the patients' persistent symptoms. MRI helps in revealing indirect signs of a low volume of CSF, though it may not be possible to locate the actual site of the leak. In conclusion, EBP is a well-accepted and beneficial treatment modality for SIH when conventional measures fail.
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Affiliation(s)
- Zoi Masourou
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Nikolaos Papagiannakis
- Department of Neurology, Aiginiteion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (N.P.); (D.-D.M.)
| | | | - Dimos-Dimitrios Mitsikostas
- Department of Neurology, Aiginiteion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (N.P.); (D.-D.M.)
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Correspondence:
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13
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Lashkarivand A, Eide PK. Brain Sagging Dementia -- Diagnosis, Treatment, and Outcome: A Review. Neurology 2022; 98:798-805. [PMID: 35338080 DOI: 10.1212/wnl.0000000000200511] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Brain sagging dementia (BSD), caused by spontaneous intracranial hypotension (SIH), is a rare syndrome that is only recently recognized, mimicking the clinical findings of behavioral variant frontotemporal dementia (bvFTD). Being aware of its signs and symptoms is essential for early diagnosis and treatment in this potentially reversible form of dementia. Our objective was to identify cases with BSD in the literature and present its clinical characteristics, diagnostic workup, treatment options, and outcome.The review was reported according to PRISMA guidelines and registered with the PROSPERO database (CRD42020150709). MEDLINE, EMBASE, PsychINFO, and Cochrane Library were searched. There was no date restriction. The search was updated in April 2021.A total of 983 articles were screened and assessed for eligibility. Twenty-nine articles (25 case reports and four series) and 70 patients were selected for inclusion. No cranial leak cases were identified. BSD diagnosis should be made based on clinical signs and symptoms and radiological findings. There is a male predominance (F: M ratio 1:4) and a peak incidence in the 6th decade of life. The main clinical manifestation is insidious onset, gradually progressive cognitive and behavioral changes characteristic for bvFTD. Headache is present in the majority of patients (89%). The presence of brain sagging and absence of frontotemporal atrophy is an absolute criterion for the diagnosis. The CSF leak is identified with myelography and digital subtraction myelography. The treatment and repair depend on the etiology and extent of the dural defect, although an epidural blood patch is the first-line treatment in most cases. With treatment, 81% experienced partial and 67% complete resolution of their symptoms. This review highlights the most important clinical aspects of BSD. Due to the sparse evidence and lack of BSD awareness, many patients are most likely left undiagnosed. Recognizing this condition is essential to provide early treatment to reverse the cognitive and behavioral changes that may otherwise progress and fully impair the patient. Moreover, patients with longstanding SIH must be carefully assessed for cognitive and behavioral changes.
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Affiliation(s)
- Aslan Lashkarivand
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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14
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Choi SH, Lee YY, Kim WJ. Epidural blood patch for spontaneous intracranial hypotension with subdural hematoma: A case report and review of literature. World J Clin Cases 2022; 10:388-396. [PMID: 35071543 PMCID: PMC8727273 DOI: 10.12998/wjcc.v10.i1.388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/23/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leakage at C1/2 in spontaneous intracranial hypotension (SIH) is rare. Subdural hematoma (SDH), a serious complication of SIH, may lead to neurological deficits. This report presents a case of SDH after spontaneous C1/2 CSF leakage, which was treated with a targeted epidural blood patch (EBP).
CASE SUMMARY A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache, nausea, and vomiting. Brain computed tomography imaging revealed bilateral, subacute to chronic SDH. Brain magnetic resonance imaging (MRI) findings were SDH with dural enhancement in the bilateral cerebral convexity and posterior fossa and mild sagging, suggesting SIH. Although the patient underwent burr hole trephination, the patient’s orthostatic headache was aggravated. MR myelography led to a suspicion of CSF leakage at C1/2. Therefore, we performed a targeted cervical EBP using an epidural catheter under fluoroscopic guidance. At 5 d after EBP, a follow-up MR myelography revealed a decrease in the interval size of the CSF collected. Although his symptoms improved, the patient still complained of headaches; therefore, we repeated the targeted cervical EBP 6 d after the initial EBP. Subsequently, his headache had almost disappeared on the 8th day after the repeated EBP.
CONCLUSION Targeted EBP is an effective treatment for SDH in patients with SIH due to CSF leakage at C1/2.
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Affiliation(s)
- Se Hee Choi
- Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, South Korea
| | - Youn Young Lee
- Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul 07985, South Korea
| | - Won-Joong Kim
- Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul 07985, South Korea
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Wei TT, Huang H, Chen G, He FF. Management of an intracranial hypotension patient with diplopia as the primary symptom: A case report. World J Clin Cases 2021; 9:6544-6551. [PMID: 34435024 PMCID: PMC8362549 DOI: 10.12998/wjcc.v9.i22.6544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/18/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intracranial hypotension (IH) is a disorder involving cerebrospinal fluid (CSF) hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed, especially in these patients without the prototypical manifestation of an orthostatic headache. At present, the management of IH with both cranial nerve VI palsy and bilateral subdural hematomas (SDHs) is still unclear.
CASE SUMMARY A 67-year-old male Chinese patient complained of diplopia on the left side for one and a half mo. Computed tomography revealed bilateral SDHs and a midline shift. However, neurotrophic drugs were not effective, and 3 d after admission, he developed a non-orthostatic headache and neck stiffness. Enhanced magnetic resonance imaging revealed dural enhancement as an additional feature, and IH was suspected. Magnetic resonance myelography was then adopted and showed CSF leakage at multiple sites in the spine, confirming the diagnosis of having IH. The patient fully recovered following multiple targeted epidural blood patch (EBP) procedures.
CONCLUSION IH is a rare disease, and to the best of our knowledge, IH with diplopia as its initial and primary symptom has never been reported. In this study, we also elucidated that it could be safe and effective to treat IH patients with associated cranial nerve VI palsy and bilateral SDHs using repeated EBP therapy.
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Affiliation(s)
- Ting-Ting Wei
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Hua Huang
- Department of Pain Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Gang Chen
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Fei-Fang He
- Department of Pain Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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16
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Novel risk factors and management of brain sag after brain tumor surgery. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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17
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A systematic review and meta-analysis of factors affecting the outcome of the epidural blood patching in spontaneous intracranial hypotension. Neurosurg Rev 2021; 44:3079-3085. [PMID: 33611638 DOI: 10.1007/s10143-021-01505-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/20/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an often misdiagnosed condition resulting from non-iatrogenic cerebrospinal fluid (CSF) hypovolemia, typically secondary to spinal CSF leakage. Patients commonly present with posture-related headache, nausea, and vomiting. Following failure of conservative measures, epidural blood patching (EBP) is the most commonly performed intervention for spinal CSF leaks. The authors performed a systematic review and meta-analysis of existing literature to evaluate the role of different factors possibly affecting the efficacy of the EBP procedure. In accordance with the PRISMA guidelines, PubMed/Medline and SCOPUS databases were searched. Six eligible articles were retrieved. Five hundred patients were treated for SIH with EBP, of which 300 reported good response defined as complete remission of symptoms within 48 h after the first EBP requiring no further invasive treatment. Among the factors available for meta-analysis, none was found to be statistically significant in affecting the efficacy of the EBP procedure. A largely symmetrical funnel plot is reported for all the variables evaluated, indicating that publication bias did not play a significant role in the observed effects. The current knowledge about SIH and the EBP is scarce. The existing literature is contradictory and insufficient to aid in clinical practice. More studies are needed to draw significant conclusions that may help in the identification of patients at higher risk of EBP failure, who may benefit from different approaches.
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18
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Cloquell A, Kaczmarska A, Gutierrez-Quintana R, José-López R. Magnetic resonance imaging findings and clinical management of suspected intracranial hypovolemia after transfrontal craniotomy in a dog. Vet Surg 2021; 50:1696-1703. [PMID: 33609047 DOI: 10.1111/vsu.13586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/24/2020] [Accepted: 12/20/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To report the diagnosis and clinical management of a case of suspected intracranial hypovolemia (IH) in a dog after resection of a large fronto-olfactory chordoid meningioma. STUDY DESIGN Clinical case report. ANIMAL One 8-year-old border collie with forebrain neurological signs caused by a fronto-olfactory extra-axial mass diagnosed by using MRI. METHODS The dog underwent bilateral transfrontal craniotomy for excision of the mass by using ultrasonic aspiration. Immediate postsurgical MRI revealed complete gross resection with no evidence of early-onset complications such as edema, hemorrhage, mass effect, or pneumoencephalus. However, diffuse symmetric meningeal thickening and contrast enhancement were noted. No complications were noted during surgery or while under anesthesia. RESULTS Neurological deterioration was observed postoperatively. No abnormalities were detected systemically. Thus, early MRI-confirmed findings and neurological deterioration were suspected to be caused by IH. Conservative treatment consisting of bed rest, gabapentin, and intravenous theophylline was then initiated in addition to steroids, antiepileptic drugs, and antibiotics. A gradual neurological improvement was observed, and the dog was discharged completely ambulatory with moderate proprioceptive ataxia 15 days after surgery. CONCLUSION The clinical and MRI-confirmed findings reported here are consistent with IH, a well-described syndrome in man. This is the first report of a dog with MRI-confirmed findings consistent with IH describing subsequent response to medical management. CLINICAL SIGNIFICANCE Intracranial hypovolemia after craniotomy should be considered when there is neurological deterioration and characteristic MRI-confirmed findings.
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Affiliation(s)
- Ana Cloquell
- Small Animal Hospital, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Adriana Kaczmarska
- Small Animal Hospital, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | | | - Roberto José-López
- Small Animal Hospital, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
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Tatum PS, Anderson E, Kravtsova A, Alnasser O, Hedges T, Green-Laroche DM, Madan N. Rapid Cognitive Decline Secondary to CSF Venous Fistula With Postoperative Rebound Intracranial Hypertension and a Hyperintense Paraspinal Vein Sign Seen Retrospectively. Mil Med 2021; 186:e265-e269. [PMID: 32918812 DOI: 10.1093/milmed/usaa204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/12/2020] [Accepted: 09/12/2020] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
A 56-year-old female with 2 prior Chiari decompressions presented with rapidly progressive cognitive decline. Brain magnetic resonance imaging, computed tomography myelogram, and prone digital subtraction myelography revealed signs of brain sag and left T9 perineural cysts but no cerebrospinal fluid leaks. Symptoms improved after multilevel blood patches but recurred. Lateral decubitus digital subtraction myelography revealed a spinal cerebrospinal fluid venous fistula (SCVF), which resolved after neurosurgeons ligated the nerve root. Rebound headaches with papilledema occurred on postoperative day 9 and then resolved 2 months after acetazolamide was started. A hyperintense paraspinal vein was seen retrospectively on T2-weighted magnetic resonance imaging with Dixon fat suppression sequencing. This case is unique in the acuity of cognitive decline secondary to SCVF. Acetazolamide at the time of treatment may potentially be used as prophylaxis for rebound intracranial hypertension. The hyperintense paraspinal vein may have utility in future diagnosis of SCVF.
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Affiliation(s)
- Peter S Tatum
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Emily Anderson
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Alina Kravtsova
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Osamah Alnasser
- TUFTS Neurology, 260 Tremont Street, 12th Floor, Boston, MA 02116
| | - Thomas Hedges
- TUFTS Neuro-Ophthalmology, 260 Tremont Street, 11th Floor, Boston, MA 02111
| | | | - Neel Madan
- TUFTS Department of Radiology, 800 Washington St Box 299, Boston, MA 02111
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Osada Y, Shibahara I, Nakagawa A, Sakata H, Niizuma K, Saito R, Kanamori M, Fujimura M, Suzuki S, Tominaga T. Unilateral chronic subdural hematoma due to spontaneous intracranial hypotension: a report of four cases. Br J Neurosurg 2020; 34:632-637. [PMID: 31535558 DOI: 10.1080/02688697.2019.1667482] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/18/2019] [Accepted: 09/10/2019] [Indexed: 10/26/2022]
Abstract
Background: Chronic subdural hematoma (CSDH) is a common neurosurgical disease. A subset of patients with CSDH may exhibit underlying spontaneous intracranial hypotension (SIH). Bilateral CSDH has a causal relationship with SIH, but there is no known causal relationship between unilateral CSDH and SIH.Case description: We encountered four cases of unilateral CSDH due to SIH. The patients' age ranged between 44 and 64 years; there were three males and one female. All patients presented with headache as their initial symptom, and then became comatose. Computed tomography demonstrated unilateral CSDH and transtentorial herniation in all patients. Treatments were emergency epidural blood patch (EBP) and evacuation of CSDH. The site of cerebrospinal fluid leak could not be identified in three patients; therefore, EBP was performed at upper and lower spine. All patients recovered from SIH; however, one patient experienced poor outcome due to Duret hemorrhage and ischemic complications of transtentorial herniation. Cranial asymmetry was present in all four patients, and unilateral CSDH was located on the side of the most curved cranial convexity.Conclusions: Unilateral CSDH, asymmetric cranial morphology, and transtentorial herniation in relatively young patients may indicate underlying SIH.
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Affiliation(s)
- Yoshinari Osada
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ichiyo Shibahara
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsuhiro Nakagawa
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyuki Sakata
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masayuki Kanamori
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shinsuke Suzuki
- Department of Neurosurgery, Sendai Medical Center, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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21
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Shim HK, Park YK. Misdiagnosis of Spontaneous Intracranial Hypotension Presenting as Acute Mental Deterioration Caused by Unilateral Acute Subdural Hematoma: Case Report. Korean J Neurotrauma 2020; 16:254-261. [PMID: 33163434 PMCID: PMC7607012 DOI: 10.13004/kjnt.2020.16.e32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 01/23/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) is usually a benign disease which mostly present as orthostatic headache and resolves by conservative treatment or epidural blood patch. However, in severe cases large subdural hematoma or brain caudal herniation can progress to brain herniation and neurologic complications. We introduce a rare case of SIH which presented as acute mental deterioration with unilateral acute subdural hematoma. A 60 years old female visited to emergency room for stuporous mental change and unilateral acute subdural hematoma. Decompressive craniectomy and hematoma removal was performed to release brain herniation and increased intracranial pressure. There was temporary improvement of consciousness, but sustained leakage of cerebrospinal fluid (CSF) and caudal brain herniation worsened patient's condition. After recognizing that CSF leakage and hypovolemia was the underlying disease, emergent epidural blood patch and early cranioplasty was performed. After treatment CSF volume was normalized and patient recovered completely without neurologic deficits. Acute mental deterioration with unilateral subdural hematoma is a rare presentation for SIH. Treatment strategy for subdural hematoma with concomitant SIH patients, should be planned carefully with concerns to CSF hypovolemia and intracranial pressure.
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Affiliation(s)
- Hyeong Kyun Shim
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yung Ki Park
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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22
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Dehaene S, Biesemans J, Van Boxem K, Vidts W, Sterken J, Van Zundert J. Post-Dural Puncture Headache Evolving to a Subdural Hematoma: A Case Report. Pain Pract 2020; 21:83-87. [PMID: 32652880 PMCID: PMC7818122 DOI: 10.1111/papr.12937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 12/25/2022]
Abstract
Introduction Cervical epidural corticosteroid injections are frequently used for the treatment of subacute cervicobrachial pain. This therapy is considered safe, with the vast majority of the complications being minor and transient. Case Report We present a case of a woman in her fifties who suffered from cervicobrachialgia and received 2 cervical epidural corticosteroid infiltrations. On day 3 after the second infiltration, a new headache appeared and on day 16 a bilateral subdural hematoma was visualized on CT scan. Complete resorption of the hematoma was seen on day 25 without surgical intervention. Discussion Up until now, only 1 case report of an intracranial subdural hematoma after a cervical epidural steroid injection has been published. But several cases of an intracranial subdural hematoma after spinal, epidural, or combined spinal and epidural anesthesia have been reported. Physicians should be aware of this potentially dramatic complication since post‐dural puncture headache after any type of procedure can evolve into a subdural hematoma. Clinical differentiation between the two can be difficult; post‐dural puncture headache is characterized by relief of symptoms in the supine position and photophobia/phonophobia. A subdural hematoma should be considered if the headache changes in character, does not respond to treatment, or there are neurological signs such as nausea/vomiting and blurred vision. Immediate medical imaging should then be performed.
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Affiliation(s)
- Seppe Dehaene
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium.,Department of Anesthesiology, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jeroen Biesemans
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium
| | - Koen Van Boxem
- Department of Anesthesiology, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wesley Vidts
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium
| | - Joeri Sterken
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium
| | - Jan Van Zundert
- Department of Anesthesiology, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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23
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Beck J, Häni L, Ulrich CT, Fung C, Jesse CM, Piechowiak E, Z’Graggen W, Meier N, Raabe A. Diagnostic challenges and therapeutic possibilities in spontaneous intracranial hypotension. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2018. [DOI: 10.1177/2514183x18787371] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jürgen Beck
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg, Germany
| | - Levin Häni
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland
| | | | - Christian Fung
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg, Germany
| | | | - Eike Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, Bern, Switzerland
| | - Werner Z’Graggen
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Niklaus Meier
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland
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24
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Motoyama Y, Nakajima T, Takamura Y, Nakazawa T, Wajima D, Takeshima Y, Matsuda R, Tamura K, Yamada S, Yokota H, Nakagawa I, Nishimura F, Park YS, Nakamura M, Nakase H. Risk of brain herniation after craniotomy with lumbar spinal drainage: a propensity score analysis. J Neurosurg 2018; 130:1710-1720. [PMID: 29882706 DOI: 10.3171/2017.12.jns172215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lumbar spinal drainage (LSD) during neurosurgery can have an important effect by facilitating a smooth procedure when needed. However, LSD is quite invasive, and the pathology of brain herniation associated with LSD has become known recently. The objective of this study was to determine the risk of postoperative brain herniation after craniotomy with LSD in neurosurgery overall. METHODS Included were 239 patients who underwent craniotomy with LSD for various types of neurological diseases between January 2007 and December 2016. The authors performed propensity score matching to establish a proper control group taken from among 1424 patients who underwent craniotomy and met the inclusion criteria during the same period. The incidences of postoperative brain herniation between the patients who underwent craniotomy with LSD (group A, n = 239) and the matched patients who underwent craniotomy without LSD (group B, n = 239) were compared. RESULTS Brain herniation was observed in 24 patients in group A and 8 patients in group B (OR 3.21, 95% CI 1.36-8.46, p = 0.005), but the rate of favorable outcomes was higher in group A (OR 1.79, 95% CI 1.18-2.76, p = 0.005). Of the 24 patients, 18 had uncal herniation, 5 had central herniation, and 1 had uncal and subfalcine herniation; 8 patients with other than subarachnoid hemorrhage were included. Significant differences in the rates of deep approach (OR 5.12, 95% CI 1.8-14.5, p = 0.002) and temporal craniotomy (OR 10.2, 95% CI 2.3-44.8, p = 0.002) were found between the 2 subgroups (those with and those without herniation) in group A. In 5 patients, brain herniation proceeded even after external decompression (ED). Cox regression analysis revealed that the risk of brain herniation related to LSD increased with ED (hazard ratio 3.326, 95% CI 1.491-7.422, p < 0.001). Among all 1424 patients, ED resulted in progression or deterioration of brain herniation more frequently in those who underwent LSD than it did in those who did not undergo LSD (OR 9.127, 95% CI 1.82-62.1, p = 0.004). CONCLUSIONS Brain herniation downward to the tentorial hiatus is more likely to occur after craniotomy with LSD than after craniotomy without LSD. Using a deep approach and craniotomy involving the temporal areas are risk factors for brain herniation related to LSD. Additional ED would aggravate brain herniation after LSD. The risk of brain herniation after placement of a lumbar spinal drain during neurosurgery must be considered even when LSD is essential.
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25
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Yagi T, Horikoshi T, Senbokuya N, Murayama H, Kinouchi H. Distribution Patterns of Spinal Epidural Fluid in Patients with Spontaneous Intracranial Hypotension Syndrome. Neurol Med Chir (Tokyo) 2018; 58:212-218. [PMID: 29710056 PMCID: PMC5958043 DOI: 10.2176/nmc.oa.2017-0227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The aim of this study is to clarify the details of distribution patterns of spinal epidural fluid and to establish it as measure of spontaneous intracranial hypotension (SIH) syndrome diagnosis. Magnetic resonance imaging findings of the spine were analyzed in 37 patients, 24 women and 13 men (mean age 46.3 years), with SIH. Detection rate, thickness and patterns of the fluid collection were evaluated at every vertebral level. Follow-up spinal MRI findings were also analyzed for changes in epidural fluid collection and association with clinical symptoms. The MR images of the cervical spine were obtained in 30 patients, the thoracic spine in 36, and the lumbar spine in 17 patients. Epidural fluid collection was detected totally in 36 patients (97%) and was predominantly found at the mid-thoracic vertebrae. The fluid tended to locate dorsal to the dural sac at the thoracic spine and ventral at the cervical and lumbar spine. Patients with shorter duration of illness tended to have thicker fluid in the thoracic spine. In follow-up MRI, the findings of epidural fluid collection has disappeared in 32/36 cases within 3 months after treatment. Although residual fluid collection was found at the thoracic level in 4 cases, clinical symptoms were improved in all patients. This study suggested that the mid-thoracic spine should be chosen as the target of MRI in screening of SIH, and enlarged dorsal epidural space is strongly indicative of SIH.
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Affiliation(s)
- Takashi Yagi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Toru Horikoshi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi.,Nishijima Hospital
| | - Nobuo Senbokuya
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Hiroaki Murayama
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
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26
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Schievink WI, Maya MM, Moser FG, Jean-Pierre S, Nuño M. Coma. Neurology 2018; 90:e1638-e1645. [DOI: 10.1212/wnl.0000000000005477] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/05/2018] [Indexed: 01/03/2023] Open
Abstract
ObjectiveTo review our experience with patients with spontaneous intracranial hypotension (SIH) and coma because, although disorders of consciousness may complicate SIH, no comprehensive study of such patients has been reported.MethodsUsing a prospectively maintained registry, we identified all patients with SIH in whom coma developed. Patients or their caregivers/families were contacted for follow-up. Patients were compared to a cohort of patients with SIH without coma.ResultsThe mean age of the 12 men and 3 women with SIH was 56.2 years (range 34–72 years) at the time of onset of coma. In one-third of patients, coma developed after craniotomy for subdural hematomas or for an unrelated intracranial pathology. Imaging showed brain sagging, including bilateral temporal lobe herniation, in all 15 patients and brainstem edema in 8 patients (53%). Overall, coma was reversible in 7 of 15 patients treated with epidural blood patches, in 2 of 4 treated with percutaneous glue injections, and in 6 of 6 treated surgically. Only 1 patient had residual neurologic deficit related to coma (Glasgow Outcome Scale score 4 [moderate disability]). Compared to patients with SIH without coma (n = 568), those with coma were older, more often were male, and more often underwent surgery.ConclusionsComa in SIH is rare, reversible, and invariably associated with brain sagging. Coma due to SIH may be refractory to the usual percutaneous procedures, and surgical closure of the CSF leak may be required to regain consciousness.
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27
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Treatment and outcome of subdural hematoma in patients with spontaneous intracranial hypotension: a report of 35 cases. Acta Neurol Belg 2018; 118:61-70. [PMID: 29052799 DOI: 10.1007/s13760-017-0845-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 10/01/2017] [Indexed: 01/13/2023]
Abstract
Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, low CSF pressure and diffuse pachymeningeal enhancement on brain MRI. SIH results from spontaneous CSF leakage leading to brain sag. Sometimes, tearing of bridging veins may produce subdural hematomas (SDHs). Patients with SDH were identified retrospectively from 212 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, treatment and outcome of SDH. Thirty-five patients (16%), (6 women, 29 men; aged 33-68; mean, 50 years) with SDH were recruited. They were divided into two groups: initially withSIH diagnosed (n = 29) and undiagnosed (n = 6). After conservative treatment, the first group underwent a lumbar epidural blood patch (EBP) (n = 27) and emergent evacuation of symptomatic SDH (n = 2). After EBP, ten patients had enlarged SDH. Nine of them underwent evacuation of symptomatic SDH with mass effect (ME). In the second group, three patients with clinical worsening from SIH underwent, erroneously, evacuation of mild SDH. They worsened after the evacuation; after SIH diagnosis was made, they underwent one EBP (n = 2) and three EBPs (the patient with coma). The other three cases with symptomatic SDH with ME underwent evacuation with recurrence of SDH (n = 2). All 35 patients enjoyed a good outcome. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation. When an emergent evacuation is necessary before EBP, it is preferable to perform, after surgery, one early EBP before the patient gets up to prevent frequent recurrences of SDH by underlying CSF leakage.
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Low JCM, Shtaya A, Hettige S. Intracranial Hypotension Following Traumatic Brain Injury: A Diagnostic and Therapeutic Challenge. World Neurosurg 2017. [PMID: 28624560 DOI: 10.1016/j.wneu.2017.06.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intracranial hypotension (IH) is a recognized cause of coma; however, the diagnosis is often challenging, especially in patients with superimposed traumatic brain injury. CASE DESCRIPTION A 67-year-old woman became comatose following evacuation of bilateral acute subdural hematomas with concurrent respiratory failure. Imaging and intraparenchymal intracranial pressure monitoring confirmed secondary IH. She was managed with an epidural blood patch and a 72-hour period in the Trendelenburg position guided by intracranial pressure monitoring and clinical assessment. She subsequently made an excellent neurologic recovery from an initial Glasgow Coma Scale score of 3 to a score of 15. CONCLUSIONS Secondary IH can easily be missed in patients who have sustained a primary brain injury. In patients with a poor neurologic recovery, clinicians should rule out secondary IH as a potential cause, as immediate treatment can lead to profound clinical improvement.
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Affiliation(s)
| | - Anan Shtaya
- Department of Neurosurgery, St George's Hospital, London, United Kingdom
| | - Samantha Hettige
- Department of Neurosurgery, St George's Hospital, London, United Kingdom
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Niraj G, Critchley P, Kodivalasa M, Dorgham M. Greater Occipital Nerve Treatment in the Management of Spontaneous Intracranial Hypotension Headache: A Case Report. Headache 2017; 57:952-955. [DOI: 10.1111/head.13095] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 01/03/2023]
Affiliation(s)
- G. Niraj
- Clinical Research Unit in Pain Medicine; University Hospitals of Leicester NHS Trust; Leicester UK
| | - Peter Critchley
- Department of Neurology; University Hospitals of Leicester NHS Trust; Leicester UK
| | - Mahesh Kodivalasa
- Advanced Trainees in Pain Medicine; University Hospitals of Leicester NHS Trust; Leicester UK
| | - Mohammed Dorgham
- Advanced Trainees in Pain Medicine; University Hospitals of Leicester NHS Trust; Leicester UK
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Iwase Y, Suzuki M, Bito H. A case report of intracranial hemorrhage after spinal anesthesia. JA Clin Rep 2017; 3:11. [PMID: 29492450 PMCID: PMC5813662 DOI: 10.1186/s40981-017-0081-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 03/01/2017] [Indexed: 11/15/2022] Open
Abstract
Background Chronic subdural hematoma (CSDH) after spinal anesthesia is a rare complication. We experienced a patient who developed CSDH after postdural puncture headache (PDPH) following combined spinal and epidural anesthesia (CSE). Case presentation A 38-week-gestation parturient with a history of previous cesarean delivery underwent elective cesarean section under CSE. She had been receiving aspirin therapy for Kawasaki disease for many years. She developed a symptom of PDPH 1 day after the surgery. Fluid administration and analgesics were started. Although the headache was relatively severe and persistent, it suddenly disappeared on the third postoperative day. Aspirin administration was restarted on the third postoperative day, and the patient was discharged 1 week after the surgery. 2 weeks after being discharged, she was readmitted to our hospital for severe headache and was diagnosed as having CSDH. An epidural blood patch was performed, resulting in resolution of the hematoma. Conclusions We experienced a case of CSDH after PDPH in a patient who was receiving aspirin therapy. Aspirin therapy should be restarted after confirmation of the absence of headache. We should consider the possibility of unexpected disappearance of PDPH in the postoperative period may be due to the development of CSDH.
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Affiliation(s)
- Yuri Iwase
- Department of Anesthesiology, Musashikosugi Hospital Nippon Medical School, 1-396 Kosugi-cho Nakahara-ku, Kawaski, Kanagawa 211-8533 Japan
| | - Manzo Suzuki
- Department of Anesthesiology, Musashikosugi Hospital Nippon Medical School, 1-396 Kosugi-cho Nakahara-ku, Kawaski, Kanagawa 211-8533 Japan
| | - Hiroyasu Bito
- Department of Anesthesiology, Musashikosugi Hospital Nippon Medical School, 1-396 Kosugi-cho Nakahara-ku, Kawaski, Kanagawa 211-8533 Japan
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Pattichis A(A, Slee M. CSF hypotension: A review of its manifestations, investigation and management. J Clin Neurosci 2016; 34:39-43. [DOI: 10.1016/j.jocn.2016.07.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/28/2016] [Accepted: 07/06/2016] [Indexed: 01/03/2023]
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Gassner HG, Schwan F, Schebesch KM. Minimally invasive surgery of the anterior skull base: transorbital approaches. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 14:Doc03. [PMID: 27453759 PMCID: PMC4940979 DOI: 10.3205/cto000118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach.
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Affiliation(s)
- Holger G Gassner
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Regensburg, Germany
| | - Franziska Schwan
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Regensburg, Germany
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Zhang J, Jin D, Pan KH. Epidural blood patch for spontaneous intracranial hypotension with chronic subdural haematoma: A case report and literature review. J Int Med Res 2016; 44:976-81. [PMID: 27225863 PMCID: PMC5536624 DOI: 10.1177/0300060516645955] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/01/2016] [Indexed: 01/03/2023] Open
Abstract
Spinal leakage of cerebrospinal fluid (CSF) is considered to be the primary cause of spontaneous intracranial hypotension (SIH). Subdural haematoma (SDH) is a serious complication of SIH. This current report presents a case of bilateral SDH with SIH that was treated with epidural blood patching (EBP). A 43-year-old male complained of experiencing orthostatic headaches for 2 months without neurological signs. The patient worsened in a local hospital and was transferred to the Sir Run Run Hospital. Brain computed tomography showed bilateral SDH with a midline shift. The patient underwent emergency trephination in the left frontal temporal region. Postoperative magnetic resonance myelography showed a CSF leak originating at the T11–L2 level. As a consequence of clinical deterioration of the patient, EBP was subsequently performed at the T12–L1 level. The headache was rapidly relieved and later the SDH was completely absorbed. This case report and literature review aims to remind clinicians that SIH can cause SDH and that EBP is a viable treatment option.
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Affiliation(s)
- Jian Zhang
- Department of Critical Care Medicine, Sir Run Run Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Dan Jin
- Department of Critical Care Medicine, Sir Run Run Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Kong-Han Pan
- Department of Critical Care Medicine, Sir Run Run Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Some cool considerations of external lumbar drainage during its widespread application in neurosurgical practice: a long way to go. Chin Neurosurg J 2016. [DOI: 10.1186/s41016-016-0033-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Agawa Y, Mineharu Y, Tani S, Adachi H, Imamura H, Sakai N. Bilateral Chronic Subdural Hematoma is Associated with Rapid Progression and Poor Clinical Outcome. Neurol Med Chir (Tokyo) 2016; 56:198-203. [PMID: 26923835 PMCID: PMC4831946 DOI: 10.2176/nmc.oa.2015-0256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Chronic subdural hematoma (CSDH) has been recognized as a benign disease, but its clinical outcome is not well documented. This study aims to expand the knowledge base regarding the outcome of CSDH. We retrospectively reviewed clinical characteristics of CSDH operated in the Kobe City Medical Center General Hospital between June 2005 and June 2012. Variants included age at onset, sex, laterality, presence of headache, consciousness level, and risk factors for hemorrhage such as malignancy or intake of anticoagulants. A total of 368 cases were analyzed. Six patients (1.4%) had a poor outcome, defined as any morbidity or mortality at 7 days postoperatively. Bilateral hematoma was significantly associated with a poor outcome (p = 0.041). Warfarin use and malignancy, albeit statistically not significant, were more frequently observed in patients with a poor outcome. Bilateral CSDH was observed in 53 patients (14.4%). Age at onset, sex, history of malignancy, anticoagulant use, and antiplatelet use did not differ between bilateral and unilateral CSDH. Recurrence rate was not different between bilateral and unilateral CSDH (14.2% vs. 11.3%), but poor outcome as a result of brain herniation was significantly higher in bilateral than in unilateral hematomas (5.7% vs. 0.3%, p = 0.01). Bilateral CSDH was associated with rapid progression and showed worse outcome as a result of brain herniation in comparison with unilateral CSDH. Urgent trephination surgery for decompression of hematoma pressure may be recommended for bilateral CSDH.
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Affiliation(s)
- Yuji Agawa
- Department of Neurosurgery, Kobe City Medical Center General Hospital
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Tanweer O, Kalhorn SP, Snell JT, Wilson TA, Lieber BA, Agarwal N, Huang PP, Sutin KM. Epidural Blood Patch Performed for Severe Intracranial Hypotension Following Lumbar Cerebrospinal Fluid Drainage for Intracranial Aneurysm Surgery. Retrospective Series and Literature Review. J Cerebrovasc Endovasc Neurosurg 2015; 17:318-23. [PMID: 27065093 PMCID: PMC4823429 DOI: 10.7461/jcen.2015.17.4.318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 09/21/2014] [Accepted: 08/10/2015] [Indexed: 01/29/2023] Open
Abstract
Intracranial hypotension (IH) can occur following lumbar drainage for clipping of an intracranial aneurysm. We observed 3 cases of IH, which were all successfully treated by epidural blood patch (EBP). Herein, the authors report our cases.
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Affiliation(s)
- Omar Tanweer
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Stephen P Kalhorn
- Department of Neurosurgery, Medical University of South Carolina, SC, USA
| | - Jamaal T Snell
- Department of Anesthesiology, New York University School of Medicine, New York, NY, USA
| | - Taylor A Wilson
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Bryan A Lieber
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paul P Huang
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Kenneth M Sutin
- Department of Anesthesiology, New York University School of Medicine, New York, NY, USA
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Spontaneous Intracranial Hypotension: Characteristics of the Serious Form in a Series of 24 Patients. World Neurosurg 2015; 84:1613-20. [DOI: 10.1016/j.wneu.2015.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/03/2015] [Accepted: 07/04/2015] [Indexed: 12/26/2022]
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Bonow RH, Bales JW, Morton RP, Levitt MR, Zhang F. Reversible coma and Duret hemorrhage after intracranial hypotension from remote lumbar spine surgery: case report. J Neurosurg Spine 2015; 24:389-93. [PMID: 26588496 DOI: 10.3171/2015.6.spine1521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial hypotension is a rare condition caused by spontaneous or iatrogenic CSF leaks that alter normal CSF dynamics. Symptoms range from mild headaches to transtentorial herniation, coma, and death. Duret hemorrhages have been reported to occur in some patients with this condition and are traditionally believed to be associated with a poor neurological outcome. A 73-year-old man with a remote history of spinal fusion presented with syncope and was found to have small subdural hematomas on head CT studies. He was managed nonoperatively and discharged with a Glasgow Coma Scale score of 15, only to return 3 days later with obtundation, fixed downward gaze, anisocoria, and absent cranial nerve reflexes. A CT scan showed Duret hemorrhages and subtle enlargement of the subdural hematomas, though the hematomas remained too small to account for his poor clinical condition. Magnetic resonance imaging of the spine revealed a large lumbar pseudomeningocele in the area of prior fusion. His condition dramatically improved when he was placed in the Trendelenburg position and underwent repair of the pseudomeningocele. He was kept flat for 7 days and was ultimately discharged in good condition. On long-term follow-up, his only identifiable deficit was diplopia due to an internuclear ophthalmoplegia. Intracranial hypotension is a rare condition that can cause profound morbidity, including tonsillar herniation and brainstem hemorrhage. With proper identification and treatment of the CSF leak, patients can make functional recoveries.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - James W Bales
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Ryan P Morton
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
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TAKAHASHI K, MIMA T, AKIBA Y. Chronic Subdural Hematoma Associated with Spontaneous Intracranial Hypotension: Therapeutic Strategies and Outcomes of 55 Cases. Neurol Med Chir (Tokyo) 2015; 56:69-76. [PMID: 26489406 PMCID: PMC4756246 DOI: 10.2176/nmc.oa.2015-0032] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 09/16/2015] [Indexed: 01/03/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) has increasingly been recognized, and it is well known that SIH is sometimes complicated by chronic subdural hematoma (SDH). In this study, 55 cases of SIH with SDH were retrospectively analyzed, focusing on therapeutic strategies and outcomes. Of 169 SIH cases (75 males, 84 females), 55 (36 males, 19 females) were complicated by SDH. SIH was diagnosed based on clinical symptoms, neuroimaging, and/or low cerebrospinal fluid pressure. Presence of orthostatic headache and diffuse meningeal enhancement on magnetic resonance imaging were regarded as the most important criteria. Among 55 SIH with SDH cases, 13 improved with conservative treatment, 25 initially received an epidural blood patch (EBP), and 17 initially underwent irrigation of the hematomas. Of the 25 initially treated with EBP, 7 (28.0%) needed SDH surgery and 18 (72.0%) recovered fully without surgery. Of 17 SDH cases initially treated with surgery, 6 (35.7%) required no EBP therapy and the other 11 (64.3%) needed EBP and/or additional SDH operations. In the latter group, 2 cases had transient severe complications during and after the procedures. One of these 2 cases developed a hoarse voice complication. Despite this single, non-severe complication, all enrolled in this study achieved good outcomes. The present study suggests that patients initially receiving SDH surgery may need additional treatments and may occasionally have complications. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation.
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Affiliation(s)
| | - Tatsuo MIMA
- Department of Neurosurgery, Sanno Hospital, Minato-ku, Tokyo
| | - Yoichi AKIBA
- Department of Neurosurgery, Akiba Hospital, Saitama, Saitama
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Stephen CD, Rojas R, Lioutas VA, Papavassiliou E, Simon DK. Complicated spontaneous intracranial hypotension treated with intrathecal saline infusion. Pract Neurol 2015; 16:146-9. [PMID: 26467251 DOI: 10.1136/practneurol-2015-001231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Christopher D Stephen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rafael Rojas
- Section of Neuroradiology, Department of Radiology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vasileios-Arsenios Lioutas
- Department of Neurology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Efstathios Papavassiliou
- Department of Neurosurgery, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - David K Simon
- Department of Neurology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Sporns PB, Zimmer S, Hanning U, Zoubi T, Wölfer J, Herbort M, Schwindt W, Niederstadt T. Acute tonsillar cerebellar herniation in a patient with traumatic dural tear and VAC therapy after complex trauma. Spine J 2015; 15:e13-6. [PMID: 25912500 DOI: 10.1016/j.spinee.2015.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/05/2015] [Accepted: 04/15/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cases of cerebral hypotension and tonsillar herniation after accidental lumbar cerebrospinal fluid (CSF) drainage or chest tube drainage with intrathoracic CSF leaks have been reported. To the authors' knowledge, this case presents the first report of severe intracranial hypotension because of suction of CSF by a Vacuum-Assisted Closure (VAC) device. PURPOSE The purpose of this study was to report a life-threatening intracranial hypotension in a polytraumatized patient after VAC therapy. STUDY DESIGN This study is a case report. METHODS A 23-year-old woman suffered of a Grade 3 open pelvic fracture after a motor vehicle accident. After a VAC therapy, the patient became nonresponsive. A cranial computer tomography (CCT) showed signs of intracranial hypotension with narrowing of the basal cisterns and sagging of the cerebellar tonsils. The VAC was removed. Further neuroradiological diagnostic showed a tear in the dural sac at the L5-S1 level. The patient consequently underwent neurosurgery. After a dural patch, she was oriented postoperatively and the CCT improved to a normal state. RESULTS Fifteen days after admission, the patient was discharged without neurologic sequelae. CONCLUSIONS Severely injured patients undergoing VAC therapy with secondary neurologic deterioration not because of head injury should be appropriately diagnosed to rule out dural laceration and cranial hypotension.
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Affiliation(s)
- Peter Bernhard Sporns
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany.
| | - Sebastian Zimmer
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany
| | - Uta Hanning
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany
| | - Tarek Zoubi
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany
| | - Johannes Wölfer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany
| | - Mirco Herbort
- Department of Trauma Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany
| | - Wolfram Schwindt
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany
| | - Thomas Niederstadt
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster 48149, Germany
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Ducros A, Biousse V. Headache arising from idiopathic changes in CSF pressure. Lancet Neurol 2015; 14:655-68. [DOI: 10.1016/s1474-4422(15)00015-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 12/24/2022]
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Chen YC, Wang YF, Li JY, Chen SP, Lirng JF, Hseu SS, Tung H, Chen PL, Wang SJ, Fuh JL. Treatment and prognosis of subdural hematoma in patients with spontaneous intracranial hypotension. Cephalalgia 2015; 36:225-31. [DOI: 10.1177/0333102415585095] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/07/2015] [Indexed: 01/16/2023]
Abstract
Objective The objective of this article is to elucidate the outcome, prognostic predictors and timing of surgical intervention for subdural hematoma (SDH) in patients with spontaneous intracranial hypotension (SIH). Methods Patients with SDH were identified retrospectively from 227 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, and treatment of SDH, which was later divided into conservative treatment, epidural blood patches (EBP), and surgical intervention. Poor outcome was defined as severe neurological sequelae or death. Results Forty-five patients (20%) with SDH (mean maximal thickness 11.9 ± 6.2 mm) were recruited. All 15 patients with SDH <10 mm achieved good outcomes by either conservative treatment or EBP. Of 30 patients with SDH ≥10 mm, patients with uncal herniation ( n = 3) had poor outcomes, even after emergent surgical evacuation ( n = 2), compared to those without ( n = 27) (100% vs. 0%, p < 0.001). Fourteen patients underwent surgical evacuation, resulting in good outcomes in all 12 who received early intervention and poor outcomes in the remaining two who received delayed intervention after Glasgow Coma Scale (GCS) score ≤8 (100% vs. 0%, p = 0.01). Conclusions Uncal herniation results in poor outcomes in patients with SIH complicated with SDH. In individuals with SDH ≥10 mm and decreased GCS scores, early surgical evacuation might prevent uncal herniation.
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Affiliation(s)
- Ying-Chu Chen
- Department of Neurology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan
| | - Yen-Feng Wang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taiwan
- Brain Research Center, National Yang-Ming University School of Medicine, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan
| | - Jie-Yuan Li
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Taiwan
| | - Shih-Pin Chen
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Brain Research Center, National Yang-Ming University School of Medicine, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan
| | - Jiing-Feng Lirng
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Shu-Shya Hseu
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taiwan
| | - Hsin Tung
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Division of Neurology, Department of Internal Medicine, Taichung Veterans General Hospital, Taiwan
| | - Po-Lin Chen
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Division of Neurology, Department of Internal Medicine, Taichung Veterans General Hospital, Taiwan
| | - Shuu-Jiun Wang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Brain Research Center, National Yang-Ming University School of Medicine, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan
| | - Jong-Ling Fuh
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
- Brain Research Center, National Yang-Ming University School of Medicine, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan
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Amemiya S, Takahashi K, Mima T, Yoshioka N, Miki S, Ohtomo K. Reversible alterations of the neuronal activity in spontaneous intracranial hypotension. Cephalalgia 2015; 36:162-71. [PMID: 25934316 DOI: 10.1177/0333102415585085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 04/11/2015] [Indexed: 11/15/2022]
Abstract
AIM The aim of this article is to investigate the pathophysiology underlying the alternation of the cognitive function and neuronal activity in spontaneous intracranial hypotension (SIH). METHODS Fifteen patients with SIH underwent resting-state functional magnetic resonance imaging and working-memory (WM) test one day before and one month after a surgical operation. Alternation of the cognitive function and spontaneous neuronal activity measured as amplitude of the low-frequency fluctuations (ALFF) and the functional connectivity of the default-mode network (DMN) and frontoparietal networks (FPNs) were evaluated. RESULTS WM performance significantly improved post-operatively. Whole-brain linear regression analysis of the ALFF revealed a positive correlation between cognitive performance change and ALFF change in the precuneus while a negative correlation was found in the bilateral orbitofrontal cortices (OFCs) and right medial frontal cortex (MFC). The ALFF changes normalised with the WM performance improvement post-operatively. The FPN activity in the right OFC was also increased pre-operatively. Partial correlation analysis revealed a significant correlation between WM performance and right OFC activity controlled for right FPN activity. CONCLUSIONS The abnormal activity of the OFCs and MFC that is not originating from the synchronous intrinsic network activity, together with the decreased activity of the central node of the DMN, could lead to cognitive impairment in SIH that is reversible through restoration of the cerebrospinal fluid.
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Affiliation(s)
- Shiori Amemiya
- Department of Radiology, Graduate School of Medicine, University of Tokyo, Japan
| | | | - Tatsuo Mima
- Department of Neurosurgery, Sanno Hospital, Japan
| | | | - Soichiro Miki
- 22nd Century Medical and Research Center, University of Tokyo, Japan
| | - Kuni Ohtomo
- Department of Radiology, Graduate School of Medicine, University of Tokyo, Japan
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Xia P, Hu XY, Wang J, Hu BB, Xu QL, Zhou ZJ, Lou M. Risk factors for subdural haematoma in patients with spontaneous intracranial hypotension. PLoS One 2015; 10:e0123616. [PMID: 25853681 PMCID: PMC4390346 DOI: 10.1371/journal.pone.0123616] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 03/03/2015] [Indexed: 01/22/2023] Open
Abstract
Subdural haematoma (SDH) is a potentially life-threatening complication in patients with spontaneous intracranial hypotension (SIH). In serious cases, SIH patients who present with SDHs develop neurological deficits, a decreased level of consciousness, or cerebral herniation, and may even require an urgent neurosurgical drainage. Despite numerous publications on SDHs, few report its potential risk factors in patients with SIH. In this study, we retrospectively investigated 93 consecutive SIH patients and divided them into an SDH group (n = 25) and a non-SDH (NSDH) group (n = 68). The clinical and radiographic characteristics of these 93 patients were analyzed, and then univariate analysis and further multiple logistic regression analysis were performed to identify the potential risk factors for the development of SDHs. The univariate analysis showed that advanced age, male gender, longer clinical course, dural enhancement, and the venous distension sign were associated with the development of SDHs. However, multivariate analysis only included the latter three factors. Our study reveals important radiological manifestations for predicting the development of SDHs in patients with SIH.
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Affiliation(s)
- Ping Xia
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Xing-Yue Hu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Jin Wang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Bei-Bei Hu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Qing-Lin Xu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
| | - Zhi-Jie Zhou
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, China
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, China
- * E-mail: (ML); (ZJZ)
| | - Min Lou
- Department of Neurology, 2nd Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
- * E-mail: (ML); (ZJZ)
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Hirono S, Kawauchi D, Higuchi Y, Setoguchi T, Kihara K, Horiguchi K, Kado K, Sato M, Fukuda K, Nakamura T, Saeki N, Yamakami I. Life-Threatening Intracranial Hypotension after Skull Base Surgery with Lumbar Drainage. J Neurol Surg Rep 2015; 76:e83-6. [PMID: 26251819 PMCID: PMC4520994 DOI: 10.1055/s-0035-1547369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/16/2014] [Indexed: 01/29/2023] Open
Abstract
Although lumbar drainage (LD) is widely used in skull base surgery (SBS), no cases with intracranial hypotension (IH) following LD-assisted SBS have been reported, and skull base surgeons lack awareness of this potentially life-threatening condition. We report two cases of IH after LD-assisted SBS, a spheno-orbital meningioma and an osteosarcoma in the orbit. Despite a minimal amount of cerebrospinal fluid (CSF) drainage and early LD removal, severe postural headache and even a deteriorating consciousness level were observed in the early postoperative course. Neuroimages demonstrated epidural fluid collections, severe midline shift, and tonsillar sag compatible with IH. Epidural blood patch (EBP) immediately and completely reversed the clinical and radiologic findings in both patients. IH should be included in the differential diagnosis of postural headache after LD-assisted SBS that can be managed successfully with EBP. Persistent leakage of CSF at the LD-inserted site leads to IH. Broad dural dissection and wide removal of bony structure may be involved in the midline shift. EBP should be performed soon after conservative management fails. Further reports will determine the risk factors for IH development following LD-assisted SBS.
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Affiliation(s)
- Seiichiro Hirono
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Daisuke Kawauchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Taiki Setoguchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Kazunori Kihara
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Kentaro Horiguchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Ken Kado
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Motoki Sato
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Kazumasa Fukuda
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Takao Nakamura
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Naokatsu Saeki
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Iwao Yamakami
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
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Inamasu J, Moriya S, Shibata J, Kumai T, Hirose Y. Spontaneous intracranial hypotension manifesting as a unilateral subdural hematoma with a marked midline shift. Case Rep Neurol 2015; 7:71-7. [PMID: 25969682 PMCID: PMC4427154 DOI: 10.1159/000381667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a syndrome in which hypovolemia of the cerebrospinal fluid (CSF) results in various symptoms. Although its prognosis is usually benign, cases with a rapid neurologic deterioration resulting in an altered mental status have been reported. One of the characteristic radiographic findings in such cases is the presence of bilateral accumulation of subdural fluid (hematoma/hygroma). When SIH-related subdural hematoma is present only unilaterally with a concomitant midline shift, making an accurate diagnosis may be challenging, and inadvertent hematoma evacuation may result in further neurologic deterioration. We report a 58-year-old woman with an altered mental status who had visited a local hospital and in whom a brain CT showed a unilateral subdural hematoma with a marked midline shift. She was referred to our department because of her neurologic deterioration after hematoma evacuation. A CT myelography revealed a massive CSF leakage in the entire thoracic epidural space. She made a full neurologic recovery following blood patch therapy. Our case is unique and educational because the suspicion for SIH as an underlying cause of subdural hematoma is warranted in nongeriatric patients not only with bilateral but also unilateral lesions. An immediate search for CSF leakage may be important in cases with failed hematoma evacuation surgery.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Japan
| | - Shigeta Moriya
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Japan
| | - Junpei Shibata
- Department of Anesthesiology, Fujita Health University Hospital, Toyoake, Japan
| | - Tadashi Kumai
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Japan
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Burns TC, Mindea SA, Pendharkar AV, Lapustea NB, Irime I, Nayak JV. Endoscopic Transnasal Approach for Urgent Decompression of the Craniocervical Junction in Acute Skull Base Osteomyelitis. J Neurol Surg Rep 2015; 76:e37-42. [PMID: 26251807 PMCID: PMC4520966 DOI: 10.1055/s-0034-1395492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/14/2014] [Indexed: 01/29/2023] Open
Abstract
Ventral epidural abscess with osteomyelitis at the craniocervical junction is a rare occurrence that typically mandates spinal cord decompression via a transoral approach. However, given the potential for morbidity with transoral surgery, especially in the setting of immunosuppression, together with the advent of extended endonasal techniques, the transnasal approach could be attractive for selected patients. We present two cases of ventral epidural abscess and osteomyelitis at the craniocervical junction involving C1/C2 that were successfully treated via the endoscopic transnasal approach. Both were treated in staged procedures involving posterior cervical fusion followed by endoscopic transnasal resection of the ventral C1 arch and odontoid process for decompression of the ventral spinal cord and medulla. Dural repairs were successfully performed using multilayered, onlay techniques where required. Both patients tolerated surgery exceedingly well, had brief postoperative hospital stays, and recovered uneventfully to their neurologic baselines. Postoperative magnetic resonance imaging confirmed complete decompression of the foramen magnum and upper C-spine. These cases illustrate the advantages and low morbidity of the endonasal endoscopic approach to the craniocervical junction in the setting of frank skull base infection and immunosuppression, representing to our knowledge a unique application of this technique to osteomyelitis and epidural abscess at the craniocervical junction.
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Affiliation(s)
- Terry C Burns
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Stefan A Mindea
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Nicolae B Lapustea
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Ioana Irime
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
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