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Park JW, Park J. Cervical Myelopathy Due to Epidural Hematoma at the Cervicomedullary Junction Associated With Ventriculoperitoneal Shunt Overdrainage: A Case Report. Brain Neurorehabil 2023; 16:e27. [PMID: 38047090 PMCID: PMC10689856 DOI: 10.12786/bn.2023.16.e27] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 12/05/2023] Open
Abstract
We present a case of cervical myelopathy caused by epidural hematoma formation due to chronic cerebrospinal fluid overdrainage. A 55-year-old man who underwent ventriculoperitoneal (V-P) shunt surgery for normal pressure hydrocephalus presented with progressive weakness of both the upper and lower extremities. Magnetic resonance imaging (MRI) revealed compressive myelopathy at the cervicomedullary junction at the C1-C2 level caused by epidural hematoma formation due to intracranial hypotension (IH) caused by a complication of V-P shunt. He underwent decompressive laminectomy and hematoma removal at C1-C2 and replacement of the V-P shunt valve. Follow-up cervical spine MRI showed an improved state of severe central spinal stenosis at the C1-C2 level and an improved state of compression-related cord signal intensity change in the spinal cord. After surgical intervention and intensive rehabilitation, the patient showed clinical improvement. If cervical myelopathy is suspected in patients with a shunt, cord compression due to venous engorgement or hematoma caused by over-shunting and IH should be considered.
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Affiliation(s)
- Ji Woong Park
- Department of Physical Medicine and Rehabilitation, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Junwon Park
- Department of Physical Medicine and Rehabilitation, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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Nas OF, Oztepe MF, Kandemirli SG, Demir AB, Bilgin C, Inecikli MF, Hakyemez B. The Efficacy and Safety of Lumbar Accessed Catheter-Assisted Epidural Blood Patch in Cervical and Thoracic Cerebrospinal Fluid Leakages. World Neurosurg 2022; 168:e233-e239. [PMID: 36162796 DOI: 10.1016/j.wneu.2022.09.087] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/17/2022] [Accepted: 09/19/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To evaluate the clinical and radiological results of lumbar accessed catheter-assisted epidural blood patch (LACA-EBP) technique in treatment of spontaneous intracranial hypotension (SIH) secondary to cervicothoracic cerebrospinal fluid (CSF) leakage. METHODS This study focuses on a selected patient population presenting with SIH where MRI cisternography confirmed and localized the CSF leakage in cervicothoracic levels. Patients were treated with LACA-EBP. Visual Analog Scale (VAS) for headache at baseline, 3rd day after treatment and during long-term follow-up was used to assess the treatment response. Post-treatment VAS on the third day ≤ 3 defined treatment success, whereas scores ≥ 4 indicated treatment failure. RESULTS A total of 10 patients underwent LACA-EBP (7 females, 3 males) with a mean age of 38.4±10.5. Orthostatic headache was the most common presenting symptom (10/10; 100%), followed by nausea (5/10; 50%). Pituitary gland enlargement was the most commonly observed finding on pre-treatment cranial MRI (9/10; 90%). On MRI cisternography, 8 patients had cervical and/or thoracic fistulae, whereas two patients had multiple fistulae levels. Technique was successful in all patients without any complication. All patients showed treatment response with a 72-hour VAS of ≤ 3. Follow-up VAS values were available for 8 patients with a mean clinical follow-up duration of 1-74 months (median: 7.5 months). During clinical follow-up, the headache had recurred in 2 patients. CONCLUSION Our study cohort suggests that LACA-EBP can be used as a safe and efficacious technique in treatment of cerebrospinal fluid leakage in cervical and thoracic levels.
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Affiliation(s)
- Omer F Nas
- Bursa Uludag University School of Medicine, Department of Radiology, Bursa, Turkey.
| | - Muhammed F Oztepe
- Bursa Uludag University School of Medicine, Department of Radiology, Bursa, Turkey
| | - Sedat G Kandemirli
- University of Iowa Hospital and Clinics, Department of Radiology, Iowa, IA, USA
| | - Aylin Bican Demir
- Bursa Uludag University School of Medicine, Department of Neurology, Bursa, Turkey
| | - Cem Bilgin
- University of Health Sciences Bursa Yuksek Ihtisas Education and Research Hospital, Department of Radiology, Bursa, Turkey
| | - Mehmet F Inecikli
- Bursa Uludag University School of Medicine, Department of Radiology, Bursa, Turkey
| | - Bahattin Hakyemez
- Bursa Uludag University School of Medicine, Department of Radiology, Bursa, Turkey
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Oh AR, Park J, Jeong JS, Lee JY, Choi JW, Kim H, Sim WS. Risk factors associated with repeated epidural blood patches using autologous blood. Korean J Pain 2022; 35:224-230. [PMID: 35354685 PMCID: PMC8977201 DOI: 10.3344/kjp.2022.35.2.224] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/16/2022] [Accepted: 02/20/2022] [Indexed: 11/05/2022] Open
Abstract
Background An epidural blood patch (EBP) is a procedure to treat intracranial hypotension that does not respond to conservative treatment. EBPs are commonly repeated when the symptoms persist. In this study, we used a large single-center retrospective cohort and evaluated the factors associated with repeated EBPs. Methods From January 2010 to December 2020, a total of 596 patients were treated with EBPs for intracranial hypotension. We evaluated the factors associated with repeated EBPs in the entire population, in patients with spontaneous intracranial hypotension (SIH), and in those with available myelographies. Results In a total of 596 patients, 125 (21.1%) patients required repeated EBPs, and 96/278 (34.5%) in SIH and 29/314 (9.2%) in iatrogenic population. In patients with SIH, international normalized ratio (INR) and cerebrospinal fluid (CSF) leakage on myelographies consistently exhibited significant associations (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.02-1.87; P = 0.043 and OR, 2.18; 95% CI, 1.28-3.69; P = 0.004). In patients with iatrogenic injury, INR and CSF leakage on myelogram did not show difference in repeated EBPs. Conclusions Repeated EBPs may be more frequently required in patients with SIH. Prolonged INR and CSF leakage were associated with repeated EBPs in patient with SIH. Further studies are needed to determine factors associated with repeated EBP requirements.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hara Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Lee CJ, Shim SM, Cho SH, Park JH, Kim YK. Iatrogenic Development of Cerebrospinal Fluid Leakage in Diagnosing Spontaneous Intracranial Hypotension. Korean J Fam Med 2018; 39:122-125. [PMID: 29629045 PMCID: PMC5876047 DOI: 10.4082/kjfm.2018.39.2.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/23/2017] [Accepted: 05/23/2017] [Indexed: 11/03/2022] Open
Abstract
A 34-year-old woman came to the emergency room complaining of a severe orthostatic headache. Results of a cerebrospinal fluid tap and brain computed tomography were normal. Based on her history and symptoms, she was found to have spontaneous intracranial hypotension. She was hospitalized and her symptoms improved with conservative treatment. On the next day, her headache suddenly worsened. Cisternography was performed to confirm the diagnosis and determine the spinal level of her cerebrospinal fluid leak. It revealed multiple cerebrospinal fluid leaks in the lumbar and upper thoracic regions. It was strongly believed that she had an iatrogenic cerebrospinal fluid leak in the lumbar region. An epidural blood patch was performed level by level on the lumbar and upper thoracic regions. Her symptoms resolved after the epidural blood patch and she was later discharged without any complications. In this case, an iatrogenic cerebrospinal fluid leak was caused by a dural puncture made while diagnosing spontaneous intracranial hypotension, which is always a risk and hampers the patient's progress. Therefore, in cases of spontaneous intracranial hypotension, an effort to minimize dural punctures is needed and a non-invasive test such as magnetic resonance imaging should be considered first.
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Affiliation(s)
- Chang-Joon Lee
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Sung-Min Shim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Sang-Hyeon Cho
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Jae-Ho Park
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Young Ki Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, Gangneung, Korea
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Michali-Stolarska M, Bladowska J, Stolarski M, Sąsiadek MJ. Diagnostic Imaging and Clinical Features of Intracranial Hypotension - Review of Literature. Pol J Radiol 2017; 82:842-849. [PMID: 29657653 PMCID: PMC5894032 DOI: 10.12659/pjr.904433] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 03/24/2017] [Indexed: 12/02/2022] Open
Abstract
Intracranial hypotension (IH) is an uncommon, benign, and usually self-limiting condition caused by low cerebrospinal fluid (CSF) pressure, usually due to CSF leakage. The dominant clinical finding is an orthostatic headache. Other common clinical features include fever, nausea, vomiting, and tinnitus. Magnetic resonance imaging (MRI) plays an important role in the diagnosis and follow-up of patients with IH. Specific MRI findings include intracranial pachymeningeal enhancement, sagging of the brain, pituitary enlargement, and subdural fluid collections. Intracranial hypotension can mimic other conditions such as aseptic meningitis or pituitary adenomas. Differential diagnosis is important, because misdiagnosis may lead to unnecessary procedures and prolonged morbidity.
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Affiliation(s)
- Marta Michali-Stolarska
- Department of General and Interventional Radiology and Neuroradiology, Wrocław Medical University, Wrocław, Poland
| | - Joanna Bladowska
- Department of General and Interventional Radiology and Neuroradiology, Wrocław Medical University, Wrocław, Poland
| | - Mateusz Stolarski
- Department of Trauma Surgery, Knappschaftskrankenhaus Bochum-Langendreer, University Hospital Bochum, Bochum, Germany
| | - Marek J Sąsiadek
- Department of General and Interventional Radiology and Neuroradiology, Wrocław Medical University, Wrocław, Poland
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Cho BH, Heo H, Park SW, Lee SH. Transient abducens nerve palsy after cervical traction. Neurol Sci 2017; 38:1709-11. [PMID: 28497308 DOI: 10.1007/s10072-017-2991-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
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Petramfar P, Mohammadi SS, Hosseinzadeh F. Treatment of Idiopathic Intracranial Hypotension With Tea: A Case Report. Iran Red Crescent Med J 2016; 18:e24620. [PMID: 27621920 PMCID: PMC5002997 DOI: 10.5812/ircmj.24620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 03/30/2015] [Accepted: 04/18/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The syndrome of spontaneous intracranial hypotension has been increasingly diagnosed since its discovery through magnetic resonance imaging (MRI). It is a rare syndrome that is due to the leakage of cerebrospinal fluid (CSF) from a tear in the dura and can occur at any age, even among adolescents, but is most frequently seen among females in late middle age. CASE PRESENTATION Here, we describe a 32-year-old woman with a two-month history of headaches and occasional nausea and vomiting (N/V). MRI without gadolinium was normal, but meningeal enhancement was seen in MRI with gadolinium. The lumbar puncture revealed a low opening pressure. Computed tomography myelography (CT myelography) showed no leakage; Therefore, idiopathic intracranial hypotension was diagnosed. Treatment was started using tea, and the patient's headache got significantly better in about a day. CONCLUSIONS Conservative therapy, such as bed rest and caffeine treatment with eight cups of tea daily, yielded a significant improvement in our patient. Effectively, the patient constitutes a case of idiopathic intracranial hypotension due to undetectable CSF leakage or hyper-absorption, with good response to conservative management through tea-drinking. Further investigations with an appropriate sample size are needed in order to confirm this intervention in the treatment of idiopathic intracranial hypotension.
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Affiliation(s)
- Peyman Petramfar
- Department of Neurology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - S. Saeed Mohammadi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding Authors: S. Saeed Mohammadi, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, IR Iran. E-mail: ; Farideh Hosseinzadeh, Shiraz University of Medical Sciences, Shiraz, IR Iran. E-mail:
| | - Farideh Hosseinzadeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding Authors: S. Saeed Mohammadi, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, IR Iran. E-mail: ; Farideh Hosseinzadeh, Shiraz University of Medical Sciences, Shiraz, IR Iran. E-mail:
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Wang E, Wang D. Successful treatment of spontaneous intracranial hypotension due to prominent cervical cerebrospinal fluid leak with cervical epidural blood patch. Pain Med 2014; 16:1013-8. [PMID: 24666583 DOI: 10.1111/pme.12418] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To report a case of successful treatment of a patient with spontaneous intracranial hypotension correlated with MRI finding of cerebrospinal fluid (CSF) leak with extradural collection at the upper cervical spinal level. DESIGN Case report. SETTING An academic tertiary pain management center. METHODS Fluoroscopically guided placement of an 18-gauge epidural needle into epidural space at the C7-T1 level was performed; an epidural catheter (Braun Perifix 20G) was advanced to C2 level (first patch) and C3 level (second patch). An epidurogram with Omnipaque injections confirmed contrast in the posterior and lateral epidural space. Autologous venous blood was then administered through the catheter. RESULTS This patient received two lumbar epidural blood patches without lasting relief. Given the radiographic evidence of prominent CSF leak with extradural fluid collection at C1-2 level, the patient was then treated with a cervical epidural blood patch, which provided headache pain relief lasting 6 months. A second cervical epidural blood patch was performed, and the patient has been headache-free for nearly one year to date. CONCLUSION Based on the successful treatment of this patient's spontaneous intracranial hypotension, we advocate that patients undergo epidural blood patches to target the site of any CSF leak identified by imaging studies to improve the efficacy of this intervention. This case demonstrates that cervical epidural blood patch, despite its inherent risks, may be more effective than lumbar epidural blood patch in treatment of cervical CSF leak.
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Affiliation(s)
- Eugene Wang
- Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Dajie Wang
- Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
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Huang CW, Tsai YF, Hsiao CY. Different MRI signs in predicting the treatment efficacy of epidural blood patch in spontaneous intracranial hypotension: a case report. Iran J Radiol 2013; 10:172-4. [PMID: 24348606 PMCID: PMC3857983 DOI: 10.5812/iranjradiol.3929] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2011] [Revised: 06/30/2012] [Accepted: 03/30/2013] [Indexed: 11/17/2022]
Abstract
Abstract The current mainstay of treatment in spontaneous intracranial hypotension (SIH) is an epidural blood patch (EBP). Although magnetic resonance imaging (MRI) has a well-established role in the diagnosis of SIH, imaging features regarding the treatment efficacy of EBP have rarely been discussed. We therefore sought to investigate and compare the sequential brain MRI studies before and after EBP by evaluating the changes of the following intracranial structures—the contour of the transverse dural sinus (TDS), tension of the pituitary stalk (or the infundibulum), and thickness of the dura mater. We found that the progressive reversals of these structures are predictive of an effective EBP.
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Affiliation(s)
- Ching Wen Huang
- Department of Diagnostic Radiology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yuh Feng Tsai
- Department of Diagnostic Radiology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
- Neuroimaging Center, Department of Health Management, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei,Taiwan
- Corresponding author: Yuh Feng Tsai, Department of Diagnostic Radiology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, R.O.C. Tel: +886-968995558, Fax: +886-223699103, E-mail:
| | - Chen Yu Hsiao
- Department of Diagnostic Radiology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Lu YY, Wang HY, Lin Y, Lin WY. The Value of Changing Position in the Detection of CSF Leakage in Spontaneous Intracranial Hypotension Using Tc-99m DTPA Scintigraphy: Two Case Reports. Iran J Radiol 2013; 9:150-3. [PMID: 23329981 PMCID: PMC3522372 DOI: 10.5812/iranjradiol.7956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 08/01/2012] [Accepted: 08/11/2012] [Indexed: 11/16/2022]
Abstract
Radionuclide Cisternography (RNC) is of potential value in pointing out the sites of cerebrospinal fluid (CSF) leakage in patients with spontaneous intracranial hypotension (SIH). In the current report, we present two patients who underwent RNC for suspected CSF leakage. Both patients underwent magnetic resonance imaging (MRI) and RNC for evaluation. We describe a simple method to increase the detection ability of RNC for CSF leakage in patients with SIH.
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Affiliation(s)
- Yu Yu Lu
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsin Yi Wang
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ying Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wan Yu Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Corresponding author: Wan-Yu Lin, Department of Nuclear Medicine, 160, Sec. 3, Chung-Kang Rd, Taichung, 407, Taiwan. Tel.: +886-423741349, Fax: +886-423741348, E-mail:
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