1
|
Beltrán S, Reisert M, Krafft AJ, Frase S, Mast H, Urbach H, Luetzen N, Hohenhaus M, Wolf K. Spinal cord motion and CSF flow in the cervical spine of 70 healthy participants. NMR IN BIOMEDICINE 2024; 37:e5013. [PMID: 37533376 DOI: 10.1002/nbm.5013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Abstract
Pulsatile spinal cord and CSF velocities related to the cardiac cycle can be depicted by phase-contrast MRI. Among patients with spontaneous intracranial hypotension, we have recently described relevant differences compared with healthy controls in segment C2/C3. The method might be a promising tool to solve clinical and diagnostic ambiguities. Therefore, it is important to understand the physiological range and the effects of clinical and anatomical parameters in healthy volunteers. Within a prospective study, 3D T2-weighted MRI for spinal canal anatomy and cardiac-gated phase-contrast MRI adapted to CSF flow and spinal cord motion for time-resolved velocity data and derivatives were performed in 70 participants (age 20-79 years) in segments C2/C3 and C5/C6. Correlations were analyzed by multiple linear regression models; p < 0.01 was required to assume a significant impact of clinical or anatomical data quantified by the regression coefficient B. Data showed that in C2/C3, the CSF and spinal cord craniocaudal velocity ranges were 4.5 ± 0.9 and 0.55 ± 0.15 cm/s; the total displacements were 1.1 ± 0.3 and 0.07 ± 0.02 cm, respectively. The craniocaudal range of the CSF flow rate was 8.6 ± 2.4 mL/s; the CSF stroke volume was 2.1 ± 0.7 mL. In C5/C5, physiological narrowing of the spinal canal caused higher CSF velocity ranges and lower stroke volume (C5/C6 B = +1.64 cm/s, p < 0.001; B = -0.4 mL, p = 0.002, respectively). Aging correlated to lower spinal cord motion (e.g., B = -0.01 cm per 10 years of aging, p < 0.001). Increased diastolic blood pressure was associated with lower spinal cord motion and CSF flow parameters (e.g., C2/C3 CSF stroke volume B = -0.3 mL per 10 mmHg, p < 0.001). Males showed higher CSF flow and spinal cord motion (e.g., CSF stroke volume B = +0.5 mL, p < 0.001; total displacement spinal cord B = +0.016 cm, p = 0.002). We therefore propose to stratify data for age and sex and to adjust for diastolic blood pressure and segmental narrowing in future clinical studies.
Collapse
Affiliation(s)
- Saúl Beltrán
- Department of Neurology and Neurophysiology, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Department of Radiology, Medical Physics, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Axel J Krafft
- Department of Radiology, Medical Physics, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sibylle Frase
- Department of Neurology and Neurophysiology, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hansjoerg Mast
- Department of Neuroradiology, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Niklas Luetzen
- Department of Neuroradiology, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Wolf
- Department of Neurology and Neurophysiology, Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
2
|
Fujii N, Nomura S, Izuma H, Ishihara H. Which Theory of Cerebrospinal Fluid Production and Absorption Do Neurosurgeons Teach to Medical Students? Survey from Medical Universities in Japan, 2022. Neurol Med Chir (Tokyo) 2024; 64:241-246. [PMID: 38719580 PMCID: PMC11230870 DOI: 10.2176/jns-nmc.2023-0277] [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: 11/24/2023] [Accepted: 02/27/2024] [Indexed: 06/18/2024] Open
Abstract
Several new studies have been conducted on cerebrospinal fluid (CSF) dynamics. Our educational guidelines, the Model Core Curriculum for Medical University, recommend access to the best current information. However, we do not know whether or when to introduce changes to this concept.We surveyed which theory of CSF dynamics taught to students by neurosurgeons. The old theory is the bulk flow theory, and the new theory explains that CSF is produced from the choroid plexus and capillaries; CSF then pulsates and drains into the venous and lymphatic systems through newly discovered pathways.Old and new theories were taught to 64.8% and 27.0% of students, respectively. The reason for teaching the old theory was to help them understand the pathogenesis of noncommunicating hydrocephalus (77.1%), whereas the reason for teaching the new theory was to teach the latest knowledge (40.0%). Physicians who wished to teach the new theory in the near future accounted for 47.3%, which was higher than those who would teach the new theory in 2022 (27.0%), and those who still wished to teach the old theory in the near future accounted for 43.2%.An education policy on CSF dynamics will be established when we interpret ventricular enlargement and its improvement by third ventriculostomy in noncommunicating hydrocephalus based on the new theory. The distributed answers in the survey shared that it is difficult to teach about CSF dynamics and provided an opportunity to discuss these issues.
Collapse
Affiliation(s)
- Natsumi Fujii
- Department of Neurosurgery, Yamaguchi University School of Medicine
| | - Sadahiro Nomura
- Department of Neurosurgery, Yamaguchi University School of Medicine
| | - Hiroshi Izuma
- Department of Neurosurgery, Yamaguchi University School of Medicine
| | | |
Collapse
|
3
|
Pineda NET, Go CLD, Valdez MCM. A Severe Case of Spontaneous Intracranial Hypotension in an Adult Asian Male Improved With Trendelenburg Positioning: A Case Report. Cureus 2024; 16:e60199. [PMID: 38868244 PMCID: PMC11168240 DOI: 10.7759/cureus.60199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/14/2024] Open
Abstract
Non-traumatic bilateral acute subdural hematomas are a rare occurrence. Etiologies typically include, but are not limited to, cortical artery bleeding, vascular lesions, coagulopathies, and spontaneous intracranial hypotension. We report a case of a 45-year-old Korean male with no known co-morbid illnesses nor history of head or neck trauma, who came to the emergency department due to a 10-day history of dizziness and head heaviness, followed by disorientation and drowsiness. The patient was diagnosed with bilateral acute subdural hematoma; hence, a bilateral posterior parietal craniotomy with evacuation of hematoma was performed. Neurologic status initially improved remarkably; however, during rehabilitation, there was recurrence of acute bilateral subdural hematoma requiring repeat surgical evacuation. There was no clinical improvement after the repeat surgery, and his condition further deteriorated in the neurosciences critical care unit showing signs of rostrocaudal deterioration at the level of diencephalon. A plain cranial CT scan was performed, which showed central herniation and "brain sagging." A diagnosis of spontaneous intracranial hypotension was considered; thus, the patient was managed by positioning him in the Trendelenburg position alternating with flat position on the bed. A search for the cerebrospinal fluid leak was commenced by performing a whole spine MRI constructive interference in steady state (CISS) protocol, which showed a longitudinal spinal anterior epidural cerebrospinal fluid leak from spinal level C2 to T1. Radionuclide cisternography did not provide definitive scintigraphic evidence of a leak. The patient gradually improved and was eventually transferred out of the neurosciences critical care unit. After days of rehabilitation in the hospital, the patient was discharged ambulatory with minimal support.
Collapse
Affiliation(s)
| | - Cybele Liana D Go
- Institute for Neurosciences, St. Luke's Medical Center, Quezon City, PHL
| | | |
Collapse
|
4
|
Khandelwal A, Sarma S, Hussain M. Sphenopalatine ganglion block for the treatment of spontaneous intracranial hypotension without demonstrable cerebrospinal fluid leak: A report of two cases. J Neurosci Rural Pract 2024; 15:387-389. [PMID: 38746504 PMCID: PMC11090561 DOI: 10.25259/jnrp_30_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/27/2024] [Indexed: 05/16/2024] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a condition characterized by orthostatic headache associated with nausea, vomiting, tinnitus, vertigo, hypoacusis, neck pain/stiffness, and photophobia. Usual treatment includes bed rest, hydration, caffeine, analgesics, epidural blood patch, steroids, fibrin glue (N-butyl-cyanoacrylate), and surgical repair. In this series, we report two cases, who presented to us with features of SIH and were managed successfully with sphenopalatine ganglion block. This is a novel modality of management of SIH and has not been reported before.
Collapse
Affiliation(s)
- Ankur Khandelwal
- Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, Guwahati, Assam, India
| | - Sanghamitra Sarma
- Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, Guwahati, Assam, India
| | - Masaraf Hussain
- Department of Neurology, All India Institute of Medical Sciences, Guwahati, Assam, India
| |
Collapse
|
5
|
Engrand N, Salardaine Q, Desilles JP, Echard C, Bourdillon P, Williams M, Baille G. Case report: Simultaneous measurement of intracranial pressure and lumbar intrathecal pressure during epidural patch therapy for treating spontaneous intracranial hypotension syndrome. Spontaneous intracranial hypotension or spontaneous intraspinal hypovolume? Front Neurol 2024; 15:1308462. [PMID: 38576535 PMCID: PMC10991849 DOI: 10.3389/fneur.2024.1308462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/24/2024] [Indexed: 04/06/2024] Open
Abstract
Objectives Spontaneous intracranial hypotension (SIH) is frequently complicated by subacute subdural hematoma (SDH) and more rarely by bilateral thalamic ischemia. Here, we report a case of SIH-related SDH treated with three epidural patches (EPs), with follow-up of the intracranial pressure and lumbar intrathecal pressure. Methods A 46-year-old man presented bilateral thalamic ischemia, then a growing SDH. After failure of urgent surgical evacuation, he underwent three saline EPs, two dynamic myelography examinations and one digital subtraction angiography-phlebography examination. However, because of no dural tear and no obstacle to the venous drainage of the vein of Galen, no therapeutic procedure was available, and the patient died. Results The case exhibited a progressive increase in the transmission of lumbar intrathecal pressure to intracranial pressure during the three EPs. The EPs may have successfully treated the SIH, but the patient did not recover consciousness because of irreversible damage to both thalami. Conclusion Clinicians should be aware of the bilateral thalamic ischemia picture that may be the presenting sign of SIH. Moreover, the key problem in the pathophysiology of SIH seems to be intraspinal and intracranial volumes rather than pressures. Therefore, intracranial hypotension syndrome might actually be an intraspinal hypovolume syndrome.
Collapse
Affiliation(s)
- Nicolas Engrand
- Neuro-Intensive Care Unit-Anesthesiology, Rothschild Foundation Hospital, Paris, France
| | | | | | - Cécile Echard
- Neuro-Intensive Care Unit-Anesthesiology, Rothschild Foundation Hospital, Paris, France
| | - Pierre Bourdillon
- Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Marc Williams
- Diagnostic Neuroradiology Department, Rothschild Foundation Hospital, Paris, France
| | - Guillaume Baille
- Neurology Department, Delafontaine Hospital, Saint-Denis, France
| |
Collapse
|
6
|
Jesse CM, Schär RT, Goldberg J, Fung C, Ulrich CT, Dobrocky T, Piechowiak EI, Schankin CJ, Beck J, Raabe A, Häni L. Patient-reported symptomatology and its course in spontaneous intracranial hypotension - Beware of a chameleon. Clin Neurol Neurosurg 2024; 236:108087. [PMID: 38134757 DOI: 10.1016/j.clineuro.2023.108087] [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: 09/22/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Although orthostatic headache is the hallmark symptom of spontaneous intracranial hypotension (SIH), patients can present with a wide range of different complaints and thereby pose a diagnostic challenge for clinicians. Our aim was to describe and group the different symptoms associated with SIH and their course over time. METHODS We retrospectively surveyed consecutive patients diagnosed and treated for SIH at our institution from January 2013 to May 2020 with a specifically designed questionnaire to find out about their symptomatology and its course. RESULTS Of 112 eligible patients, 79 (70.5%) returned the questionnaire and were included in the analysis. Of those, 67 (84.8%) reported initial orthostatic headaches, whereas 12 (15.2%) denied having this initial symptom. All except one (98.7%) patients reported additional symptoms: most frequently cephalic pressure (69.6%), neck pain (68.4%), auditory disturbances (59.5%), nausea (57%), visual disturbances (40.5%), gait disturbance (20.3%), confusion (10.1%) or sensorimotor deficits (21.5%). Fifty-seven (72.2%) patients reported a development of the initial symptoms predominantly in the first three months after symptom onset. Age and sex were not associated with the symptomatology or its course (p > 0.1). CONCLUSION Although characteristic of SIH, a relevant amount of patients present without orthostatic headaches. In addition, SIH can manifest with non-orthostatic headaches at disease onset or during the course of the disease. Most patients report a wide range of associated complaints. A high degree of suspicion is crucial for an early diagnosis and targeted treatment.
Collapse
Affiliation(s)
- Christopher Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany; Department of Neurosurgery, Lindenhofspital, Bern, Switzerland
| | | | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eike Immo Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Broom MA. Intrathecal catheterisation after accidental dural puncture: real-world data, real-world benefits and real-world barriers. Anaesthesia 2023; 78:1195-1198. [PMID: 37553790 DOI: 10.1111/anae.16116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Affiliation(s)
- M A Broom
- Department of Anaesthesia, Glasgow Royal Infirmary and Princess Royal Maternity Hospital, Glasgow, UK
| |
Collapse
|
9
|
Mehta D, Cheema S, Davagnanam I, Matharu M. Diagnosis and treatment evaluation in patients with spontaneous intracranial hypotension. Front Neurol 2023; 14:1145949. [PMID: 36970531 PMCID: PMC10036855 DOI: 10.3389/fneur.2023.1145949] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Spontaneous intracranial hypotension is characterized by an orthostatic headache and audiovestibular symptoms alongside a myriad of other non-specific symptoms. It is caused by an unregulated loss of cerebrospinal fluid at the spinal level. Indirect features of CSF leaks are seen on brain imaging as signs of intracranial hypotension and/or CSF hypovolaemia as well as a low opening pressure on lumbar puncture. Direct evidence of CSF leaks can frequently, but not invariably, be observed on spinal imaging. The condition is frequently misdiagnosed due to its vague symptoms and a lack of awareness of the condition amongst the non-neurological specialities. There is also a distinct lack of consensus on which of the many investigative and treatment options available to use when managing suspected CSF leaks. The aim of this article is to review the current literature on spontaneous intracranial hypotension and its clinical presentation, preferred investigation modalities, and most efficacious treatment options. By doing so, we hope to provide a framework on how to approach a patient with suspected spontaneous intracranial hypotension and help minimize diagnostic and treatment delays in order to improve clinical outcomes.
Collapse
Affiliation(s)
- Dwij Mehta
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- *Correspondence: Dwij Mehta
| | - Sanjay Cheema
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Indran Davagnanam
- Lysholm Department of Neuroradiology, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Manjit Matharu
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| |
Collapse
|
10
|
Piechowiak EI, Aeschimann B, Häni L, Kaesmacher J, Mordasini P, Jesse CM, Schankin CJ, Raabe A, Schär RT, Gralla J, Beck J, Dobrocky T. Epidural Blood Patching in Spontaneous Intracranial Hypotension-Do we Really Seal the Leak? Clin Neuroradiol 2023; 33:211-218. [PMID: 36028627 PMCID: PMC10014648 DOI: 10.1007/s00062-022-01205-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH). Follow-up after EBP primarily relies on clinical presentation and data demonstrating successful sealing of the underlying spinal cerebrospinal fluid (CSF) leak are lacking. Our aim was to evaluate the rate of successfully sealed spinal CSF leaks in SIH patients after non-targeted EBP. METHODS Patients with SIH and a confirmed spinal CSF leak who had been treated with non-targeted EBP were retrospectively analyzed. Primary outcome was persistence of CSF leak on spine MRI or intraoperatively. Secondary outcome was change in clinical symptoms after EBP. RESULTS In this study 51 SIH patients (mean age, 47 ± 13 years; 33/51, 65% female) treated with non-targeted EBP (mean, 1.3 EBPs per person; range, 1-4) were analyzed. Overall, 36/51 (71%) patients had a persistent spinal CSF leak after EBP on postinterventional imaging and/or intraoperatively. In a best-case scenario accounting for missing data, the success rate of sealing a spinal CSF leak with an EBP was 29%. Complete or substantial symptom improvement in the short term was reported in 45/51 (88%), and in the long term in 17/51 (33%) patients. CONCLUSION Non-targeted EBP is an effective symptomatic treatment providing short-term relief in a substantial number of SIH patients; however, successful sealing of the underlying spinal CSF leak by EBP is rare, which might explain the high rate of delayed symptom recurrence. The potentially irreversible and severe morbidity associated with long-standing intracranial hypotension supports permanent closure of the leak.
Collapse
Affiliation(s)
- Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland.
| | - Benjamin Aeschimann
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Christopher Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 8, 3010, Bern, Switzerland
| |
Collapse
|
11
|
Wolf K, Luetzen N, Mast H, Kremers N, Reisert M, Beltrán S, Fung C, Beck J, Urbach H. CSF Flow and Spinal Cord Motion in Patients With Spontaneous Intracranial Hypotension: A Phase Contrast MRI Study. Neurology 2023; 100:e651-e660. [PMID: 36357188 PMCID: PMC9969913 DOI: 10.1212/wnl.0000000000201527] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Spontaneous intracranial hypotension (SIH) is characterized by loss of CSF volume. We hypothesize that in this situation of low volume, a larger CSF flow and spinal cord motion at the upper spine can be measured by noninvasive phase contrast MRI. METHODS A prospective, age-, sex-, and body mass index (BMI)-matched controlled cohort study on patients with SIH presenting with spinal longitudinal extradural fluid collection (SLEC) was conducted from October 2021 to February 2022. Cardiac-gated 2D phase contrast MRI sequences were acquired at segment C2/C3, and C5/C6 for CSF flow, and spinal cord motion analysis. Data processing was fully automated. CSF flow and spinal cord motion were analyzed by peak-to-peak amplitude and total displacement per segment and heartbeat, respectively. Clinical data included age, height, BMI, duration of symptoms, Bern score according to Dobrocky et al., and type of the spinal CSF leak according to Schievink et al. Groups were compared via the Mann-Whitney U test; multiple linear regression analysis was performed to address possible relations. RESULTS Twenty patients with SIH and 40 healthy controls were analyzed; each group consisted of 70% women. Eleven patients with SIH presented with type 1 leak, 8 with type 2, and 1 was indeterminate. CSF flow per heartbeat was increased at C2/C3 (peak-to-peak amplitude 65.68 ± 18.3 vs 42.50 ± 9.8 mm/s, total displacement 14.32 ± 3.5 vs 9.75 ± 2.7 mm, p < 0.001, respectively). Craniocaudal spinal cord motion per heartbeat was larger at segment C2/C3 (peak-to-peak amplitude 7.30 ± 2.4 vs 5.82 ± 2.0 mm/s, total displacement 1.01 ± 0.4 vs 0.74 ± 0.4 mm, p = 0.006, respectively) and at segment C5/C6 (total displacement 1.41 ± 0.7 vs 0.97 ± 0.4 mm, p = 0.021). DISCUSSION SLEC-positive patients with SIH show higher CSF flow and higher spinal cord motion at the upper cervical spine. This increased craniocaudal motion of the spinal cord per heartbeat might produce increased mechanical strain on neural tissue and adherent structures, which may be a mechanism leading to cranial nerve dysfunction, neck pain, and stiffness in SIH. Noninvasive phase contrast MRI of CSF flow and spinal cord motion is a promising diagnostic tool in SIH. TRIAL REGISTRATION INFORMATION German Clinical Trials Register, identification number: DRKS00017351. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that noninvasive phase contrast MRI of the upper spine identifies differences in CSF flow and spinal cord motion in patients with SIH compared with healthy controls.
Collapse
Affiliation(s)
- Katharina Wolf
- From the Departments of Neurology and Neurophysiology (K.W., S.B.), Neuroradiology (N.L., H.M., N.K., H.U.), Radiology, Medical Physics (M.R.), and Neurosurgery (C.F., J.B.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Farnsworth PJ, Madhavan AA, Verdoorn JT, Shlapak DP, Johnson DR, Cutsforth-Gregory JK, Brinjikji W, Lehman VT. Spontaneous intracranial hypotension: updates from diagnosis to treatment. Neuroradiology 2023; 65:233-243. [PMID: 36336758 DOI: 10.1007/s00234-022-03079-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks, which result in continued loss of CSF volume and multiple debilitating clinical manifestations. The estimated annual incidence of SIH is 5/100,000. Diagnostic methods have evolved in recent years due to improved understanding of pathophysiology and implementation of advanced myelographic techniques. Here, we synthesize recent updates and contextualize them in an algorithm for diagnosis and treatment of SIH, highlighting basic principles and points of practice variability or continued debate. This discussion includes finer points of SIH diagnosis, CSF leak classification systems, less common types and variants of CSF leaks, brain MRI Bern scoring, potential SIH complications, key technical considerations, and positioning strategies for different types of dynamic myelography. The roles of conservative measures, non-targeted or targeted blood patches, surgery, and recently developed endovascular techniques are presented.
Collapse
Affiliation(s)
- Paul J Farnsworth
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| |
Collapse
|
13
|
Lashkarivand A, Eide PK. The first report on brain sagging dementia caused by a cranial leak: A case report. Front Neurol 2022; 13:1006060. [PMID: 36247781 PMCID: PMC9556835 DOI: 10.3389/fneur.2022.1006060] [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: 07/28/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveBrain Sagging Dementia (BSD) is an increasingly recognized syndrome for which diagnostic criteria recently were proposed. There have been no reports on BSD caused by a cranial leak. Here we present the first report on a patient with BSD caused by a cranial leak.Case descriptionA 60-year old male patient was admitted with a 2-year history of orthostatic headache and gradually progressive cognitive and behavioral changes. Traditional treatments for spontaneous intracranial hypotension, including repeated epidural blood patches, failed. Brain imaging showed severe brain sagging, and intracranial pressure monitoring demonstrated intracranial hypotension. No leakage site was found. His past medical history revealed an accident where a ski pole struck his head at age ten. Due to progressive clinical decline, surgery was pursued. A cranial defect with an accompanying cerebrospinal fluid leak site representing the trauma from his childhood was found and repaired. He also was in need of a ventriculoperitoneal shunt. Following surgery, he improved and recovered completely.DiscussionThis case report illustrates that a cranial leak may cause BSD, even with a “lucid interval” between trauma and symptom debut spanning many years. Moreover, this report validates well the recently proposed BSD diagnostic criteria.
Collapse
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
- *Correspondence: Per Kristian Eide ;
| |
Collapse
|
14
|
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.
Collapse
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:
| |
Collapse
|