Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension

BACKGROUND

We aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG).

METHODS

A 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH.

RESULTS

SIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided.

CONCLUSIONS

This multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.

Perturbations des glycémies capillaires : un effet indésirable inattendu de l’épidémie COVID-19 en TEP

Un jeûne d’environ 6 heures est requis avant l’injection de 18F-FDG afin d’éviter les états d’hyperinsulinisme susceptibles d’augmenter la captation des tissus non tumoraux, notamment musculaires. Un contrôle de la glycémie capillaire est ainsi recommandé avant toute administration de 18F-FDG. Nous rapportons une courte série de 3 patients présentant des glycémies capillaires faussement basses en lien avec l’utilisation de gel hydroalcoolique pour le lavage des mains. Les appareils de mesure de glycémie capillaire utilisent une réaction enzymatique pour mesurer la glycémie à partir des produits de dégradation de la goutte de sang déposée sur la bandelette. Trois enzymes principales peuvent être utilisées : glucose oxidase, glucose hexokinase et glucose deshydrogénase (comme dans notre appareil de mesure). Ces enzymes sont conditionnées à l’état sec sur la bandelette et sont donc sensibles aux conditions ambiantes. Le gel hydroalcoolique peut ainsi altérer la mesure. Dans notre série, les glycémies étaient artificiellement abaissées lorsque les patients avaient les mains couvertes de gel hydroalcoolique non séché avec potentiellement deux conséquences : la non détection d’une hyperglycémie ou la fausse hypoglycémie. Pour deux de ces patients, tous deux diabétiques, la question d’un resucrage immédiat et d’un report de TEP avait même été soulevée. Les guides de bonnes pratiques préconisent un lavage et un séchage des mains soigneux avant toute mesure de la glycémie capillaire, voire même l’utilisation de la seconde goutte de sang dans les cas où un bon lavage serait impossible. La consommation de gel hydroalcoolique a augmenté avec l’épidémie de COVID-19, ces potentielles interactions avec les appareils de mesure de glycémie doivent être gardées en tête.

Treatment of spontaneous intracranial hypotension: experiences in a UK regional neurosciences Centre

A robust treatment paradigm for spontaneous intracranial hypotension has yet to be agreed upon. We present retrospective data from the patient cohort at our UK regional neurosciences centre from 2010-2020 and describe our locally developed treatment pathway.Seventy-three patients were identified: 31 men and 42 women; mean age was 42 years. The majority presented with a headache of variable duration, and most had positive imaging. Very few patients (7%) responded to conservative treatment. Sixty-six underwent epidural blood patching, with 39 (59%) having a good response. Twenty-three patients underwent myelography and targeted treatment (injection of fibrin sealant at the leak site), with 13 (57%) showing a good response. One patient had successful surgery. The relapse rate after response to epidural blood patching was 10%, and after response to targeted treatment was 23%. Most patients who relapsed responded to repeated treatments.The outcome data for our diverse patient cohort shows the success of a staged approach to treatment. Relapse rates are low, and surgery is only rarely required. We use these data to inform our discussions with patients, and present them here to enable other centres to develop robust investigation and treatment paradigms of their own.