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Volz F, El Rahal A, Fung C, Shah M, Lützen N, Urbach H, Beck J, Wolf K. Don't delay, but don't despair: symptom duration, comorbidity and outcome after closure of spinal cerebrospinal fluid leaks. J Neurol 2024; 271:2776-2786. [PMID: 38409537 PMCID: PMC11055789 DOI: 10.1007/s00415-024-12242-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Microsurgical sealing of spinal cerebrospinal fluid (CSF) leaks is a viable treatment option in spontaneous intracranial hypotension (SIH). Several factors may influence the outcome, with symptom duration probably the most modifiable variable. METHODS Patients with closure of spinal CSF leaks between September 2020 and March 2023 and a follow-up period of 6 months were included in this retrospective single-center study. Pre- and postoperative scores for impact of headaches (Headache Impact Test, HIT-6) and quality of life (QoL, EQ-5D-5L) were systematically collected. Multiple regression modelling and subgroup analyses for different symptom durations and comorbidities were performed for these outcomes. RESULTS One hundred patients (61% female, median age 43.5 years) were included. Six months postoperatively, there was significant improvement in headache impact (HIT-6: 66 (IQR 62-69) to 52 (IQR 40-61, p < 0.001) and QoL (EQ-5D-5L VAS: 40 (IQR 30-60) to 79 (IQR 60-90); EQ-5D-5L Index: 0.67 (IQR 0.35-0.8) to 0.91 (IQR 0.8-0.94, p < 0.001, respectively). Subgroup analysis for a symptom duration above (74%) and below 90 days (26%) and comorbidity, as well as multiple regression analysis, revealed a trend in favor of early treatment and lower comorbidity. However, even after a prolonged symptom duration, improvements were significant. CONCLUSION As patients with shorter symptom duration show a trend for a better outcome, our results promote a timely diagnosis and treatment in SIH patients. However, a significant postoperative improvement can still be expected even after a prolonged symptom duration.
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Affiliation(s)
- Florian Volz
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
- Department of Neurosurgery, Lindenhofspital, Bern, Switzerland
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Niklas Lützen
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
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Volz F, Wolf K, Fung C, Carroll I, Lahmann C, Lützen N, Urbach H, Klingler JH, Beck J, El Rahal A. Impact of Spinal CSF Leaks on Quality of Life and Mental Health and Long-Term Reversal by Surgical Closure. Neurol Clin Pract 2024; 14:e200272. [PMID: 38585435 PMCID: PMC10996905 DOI: 10.1212/cpj.0000000000200272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/09/2024] [Indexed: 04/09/2024]
Abstract
Background and Objectives Spontaneous intracranial hypotension (SIH) caused by a spinal CSF leak is a multisymptom syndrome, which can dramatically affect physical and mental health. However, systematic data on health-related quality of life (HRQoL) and mental health are scarce. We hypothesized that surgical treatment leads to significant and sustained improvements in HRQoL and mental health in patients with SIH. Methods In this single-center cohort study, we prospectively collected HRQoL and mental health data in patients undergoing surgical closure of a spinal CSF leak from September 2020 to November 2022. EuroQoL (EQ-5D-5L), including the health state index (EQ-Index) and the visual analog scale (EQ-VAS), measured HRQoL. The 21-item version of the Depression Anxiety Stress Scales (DASS-21) measured symptoms of mental health. Follow-ups were performed 3 and 6 months postoperatively. Primary outcome was the change in EQ-Index, EQ-VAS, and DASS-21 subscales. Secondary outcome was the impact of baseline depression symptoms on HRQoL outcomes following surgery. Results Seventy-four patients were included. EQ-VAS improved from 40 (interquartile range [IQR] 30-60) preoperatively to 70 (IQR 55-85) at 3 months and to 72 (IQR 60-88) at 6 months postoperatively (p < 0.001, respectively). EQ-Index increased from 0.683 (IQR 0.374-0.799) to 0.877 (0.740-0.943) at 3 months and to 0.907 (0.780-0.956) at 6 months postoperatively (p < 0.001, respectively). Depression, anxiety, and stress significantly improved after surgery. Preoperative depressive symptoms did not affect the HRQoL outcome. Discussion The severe impact of a spinal CSF leak on HRQoL and mental health significantly improved after closure of the leak. Higher levels of depressive symptoms do not predict worse outcomes and should not discourage invasive treatment. Further systematic evaluation of outcomes, with special regard to quality of life, is needed, as it allows a comparison of symptom burden between SIH and more familiar diseases as well as a comparison of different treatment modalities in future studies.
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Affiliation(s)
- Florian Volz
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Katharina Wolf
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Ian Carroll
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Claas Lahmann
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Niklas Lützen
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Horst Urbach
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Jan-Helge Klingler
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery (FV, KW, CF, J-HK, JB, AER), Medical Center - University of Freiburg, Germany; Stanford CSF Leak Headache Program (IC), Stanford Headache Clinic, Stanford School of Medicine, CA; Department of Psychosomatic Medicine and Psychotherapy (CL); and Department of Neuroradiology (NL, HU), Medical Center - University of Freiburg, Germany
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Galvan J, Maya M, Prasad RS, Wadhwa VS, Schievink W. Spinal Cerebrospinal Fluid Leak Localization with Digital Subtraction Myelography: Tips, Tricks, and Pitfalls. Radiol Clin North Am 2024; 62:321-332. [PMID: 38272624 DOI: 10.1016/j.rcl.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Cerebrospinal fluid (CSF) leak can cause spontaneous intracranial hypotension (SIH) which can lead to neurologic symptoms, such as orthostatic headache. Over time, imaging techniques for detecting and localizing CSF leaks have improved. These techniques include computed tomography (CT) myelography, dynamic CT myelography, cone-beam CT, MRI, MR myelography, and digital subtraction myelography (DSM). DSM provides the highest sensitivity for identifying leak sites and has comparable radiation exposure to CT myelography. The introduction of the lateral decubitus DSM has proven invaluable in localizing leaks when other imaging tests have been inconclusive.
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Affiliation(s)
- Javier Galvan
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Marcel Maya
- Department of Imaging, Cedars-Sinai Medical Center; Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048.
| | - Ravi S Prasad
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Vikram S Wadhwa
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048
| | - Wouter Schievink
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard Taper Mezzanine M-335, Los Angeles, CA 90048; Department of Neurosurgery, Cedars-Sinai Medical Center
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