Application of IHS Criteria to Headache Attributed to Spontaneous Intracranial Hypotension in a Large Population

Cephalalgia ◽  
2009 ◽  
Vol 29 (4) ◽  
pp. 418-422 ◽  
Author(s):  
E Mea ◽  
L Chiapparini ◽  
M Savoiardo ◽  
A Franzini ◽  
D Grimaldi ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
International Headache Society ◽  
Large Population ◽  
Spontaneous Intracranial Hypotension ◽  
Final Diagnosis ◽  
Orthostatic Headache ◽  
Cerebral Magnetic Resonance Imaging ◽  
Blood Patch ◽  
Standing Up ◽  
Ihs Criteria

We applied the recent International Headache Society (IHS) criteria for headache related to spontaneous intracranial hypotension (SIH) to 90 consecutive patients with a final diagnosis of SIH confirmed by cerebral magnetic resonance imaging with contrast. Orthostatic headache (developing within 2 h of standing or sitting up) was present in 67 patients (75%) but appeared within 15 min after standing or sitting—as required by point A of the criteria—in only 53 (59%). Forty-four (49%) patients did not satisfy point A, including 22 (24%) with non-orthostatic headache and 14 (16%) with headache developing ≥ 15 min after standing or sitting up; 80 (89%) did not satisfy point D. Only three (3%) patients had headache fully satisfying the IHS criteria. These findings indicate that the current IHS criteria do not capture most patients with SIH-associated headache. Excluding the requirement for response to epidural blood patch (criterion D) and considering headaches appearing within 2 h of sitting or standing up would capture more patients.

scholarly journals Greater occipital nerve blockade using ultrasound guidance for the headache of spontaneous intracranial hypotension - A case report -

2021 ◽  
Author(s):  
Ji Hee Hong ◽  
Ho Woo Lee ◽  
Yong Ho Lee
Keyword(s):  
Intracranial Hypotension ◽  
Ultrasound Guidance ◽  
Spontaneous Intracranial Hypotension ◽  
Pain Clinic ◽  
Orthostatic Headache ◽  
Cerebrospinal Fluid Leakage ◽  
Nerve Blockade ◽  
Occipital Nerve ◽  
Greater Occipital Nerve ◽  
Blood Patch

BackgroundSpontaneous intracranial hypotension occurs due to cerebrospinal fluid leakage from the spinal column, and orthostatic headache is the most common clinical presentation. Recent studies showed that bilateral greater occipital nerve blockade demonstrated clinical efficacy in relieving post-dural puncture headache after caesarean section. CaseA 40-year-old male who presented severe orthostatic headache was consulted to our pain clinic from neurology department. He initially felt a dull nature pain over the whole occipital area which then spread over the frontal and parietal areas. His headache was combined with nausea and vomiting. An epidural blood patch was delayed until final cisternography, and bilateral greater occipital nerve blockade using ultrasound guidance was performed instead. After the blockade, the previously existing headache around the occipital and parietal areas disappeared completely, but mild headache persisted around the frontal area.ConclusionsGreater occipital nerve blockade could be a good therapeutic alternative to improve headache resulting from spontaneous intracranial hypotension.

scholarly journals Intracranial Hypotension with Severe Neurological Symptoms Resolved by Epidural Blood Patch

2004 ◽  
Vol 31 (4) ◽  
pp. 569-571 ◽  
Author(s):  
Philip W.H. Peng
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Short Term Memory ◽  
Spontaneous Intracranial Hypotension ◽  
Memory Loss ◽  
Sensorineural Deafness ◽  
Brain Structures ◽  
Neurological Symptoms ◽  
Orthostatic Headache ◽  
Blood Patch

Background:A patient with a constellation of severe neurological symptoms caused by spontaneous intracranial hypotension, which was successfully managed by epidural blood patch, was described.Case history:A 50-year-old woman presented to the neurological service with a two-month history of orthostatic headache. Associated clinical features included sensorineural deafness, ataxia and short-term memory loss. Magnetic resonance imaging showed downward displacement of brain structures, bilateral subdural collections and the postgadolinium images demonstrated diffuse dural enhancement suggestive of the diagnosis of spontaneous intracranial hypotension.Results:Following a lumbar epidural blood patch, all symptoms improved significantly and her headache resolved.Conclusion:The principal presentation of spontaneous intracranial hypotension is orthostatic headache. The patient described presented a combination of various neurological symptoms, ataxia, memory loss and deafness, which all responded well to epidural blood patch.

Spontaneous intracranial hypotension combined with subarachnoid hemorrhage: report of 2 cases

2020 ◽  
Author(s):  
Ya Cao ◽  
Weinan Na ◽  
Hui Su ◽  
Xiaolin Wang ◽  
Zhao Dong ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Brain Mri ◽  
Intrathecal Injection ◽  
Spontaneous Intracranial Hypotension ◽  
Orthostatic Headache ◽  
Csf Pressure ◽  
Brain Ct ◽  
Blood Patch

Abstract Background: Spontaneous intracranial hypotension (SIH) combined with subarachnoid hemorrhage (SAH) has rarely been reported. Herein, we report two patients with SIH who suffered from diffuse non-aneurysmal SAH and expanded the symptom spectrum of SIH.Case report: ① A 55-year-old male was diagnosed with SIH based on orthostatic headache and diffuse pachymeningeal enhancement on brain MRI. One more month later, his headache was exacerbated, and brain CT showed diffuse SAH. Lumber puncture showed bloody CSF with a low CSF pressure of 20 mmH2O after a 30 ml intrathecal injection of saline. The patient was treated with a lumbar epidural blood patch and recovered. ② A 41-year-old male presented with orthostatic headache and nuchal pain. The brain CT scan confirmed the diagnosis of SAH. Brain MRI revealed diffuse dural thickening and bilateral frontoparietal subdural fluid collection. Lumber puncture showed bloody CSF with low CSF pressure. Then, an epidural blood patch was performed with satisfactory results.Conclusion: Dilation and rupture of intracranial venous structures might play significant roles in SIH combined with SAH. We should be alert to SIH patients who develop a new persistent severe headache without relief after lying down or a suddenly changed state of consciousness.

Fast effective treatment of spontaenous CSF leak causing intracranial hypotension and debilitating orthostatic headache

2020 ◽  
Vol 10 (2) ◽  
pp. 36-39
Author(s):  
Heike Jacobs
Keyword(s):  
Intracranial Hypotension ◽  
Clinical Laboratory ◽  
Spontaneous Intracranial Hypotension ◽  
Case Series ◽  
Abrupt Onset ◽  
Acute Onset ◽  
Orthostatic Headache ◽  
Csf Leak ◽  
Blood Patch ◽  
Lumbar Area

We are reporting a case series describing clinical, laboratory, MRI and CT myelogram imaging and treatment results for 4 patients with spontaneous cerebral spinal fluid (CSF) leak with subsequent intracranial hypotension; all of which resolved via blood patches. A 33-year-old woman (case 1) presented abrupt onset severe pain in the back and head; without preceding trauma or procedure. MRI brain revealed leptomeningeal enhancement, after CT myelogram identifying a CSF leak she received a 20ml epidural blood patch in the lumbar area. By the next day her symptoms had completely resolved. A 36year old woman (case 2) with 1 year-long history of positional headaches. Her CT Myelogram showed frequent multilevel Tarlov Cysts; one of which displayed leakage. Her orthostatic headaches disappeared after repeated EBP. A middle aged male (case 3) had an acute onset headache which persisted with orthostatic features since 6 weeks. He had complete remission after one epidural patching. A 47 year old man (case 4) presented with 5 days of typical orthostatic headaches, CT Myelogramm demonstrated a leaking thoracolumbar cyst. He required 2 EBP within 3 days to completely recover. Our cases support the notion that blood patching is a fast, effective and safe treatment for an increasingly recognized diagnosis of orthostatic headache caused by spontaneous intracranial hypotension.

scholarly journals A spontán intracranialis hypotensio diagnosztikája mágneses rezonanciás képalkotással

2021 ◽  
Vol 162 (7) ◽  
pp. 246-251
Author(s):  
Máté Magyar ◽  
Nóra Luca Nyilas ◽  
Dániel Bereczki ◽  
György Bozsik ◽  
Gábor Rudas ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
Orthostatic Headache ◽  
Definitive Treatment ◽  
Cerebrospinal Fluid Leakage ◽  
Spinal Diseases ◽  
Minor Trauma ◽  
Blood Patch

Összefoglaló. A klasszikus esetben ortosztatikus fejfájást okozó, spontán intracranialis hypotensiót az esetek túlnyomó többségében a gerinccsatornában, annak nyaki-háti átmenetében, illetve a háti szakaszán található liquorszivárgás okozza. Meglévő kötőszöveti betegség, degeneratív gerincbetegségek, illetve kisebb traumák szerepet játszhatnak a szivárgás kialakulásában. Az ortosztatikus fejfájás létrejöttében szerepet játszhat a meningealis szerkezetek, érzőidegek és hídvénák vongálódása. A klasszikus pozicionális, ortosztatikus fejfájásban szenvedő betegek körében gondolni kell a spontán intracranialis hypotensio lehetőségére, és az agykoponya, illetve a gerinc kontrasztanyaggal végzett mágneses rezonanciás vizsgálata (MRI) javasolt. A kontrasztanyaggal végzett koponya-MRI-vel klasszikus esetben diffúz, nem nodularis, intenzív, vaskos pachymeningealis kontrasztanyag-halmozás, kitágult vénássinus-rendszer, subduralis effusiók és az agytörzs caudalis diszlokációja („slumping”) látható. Fontos azonban szem előtt tartani, hogy az esetek 20%-ában ezen eltérések nem detektálhatók. Jó minőségű, randomizált, kontrollált vizsgálatok nem történtek, a kezelés hagyományokon alapul. Kezdetben általában konzervatív terápiát alkalmaznak (ágynyugalom, koffein- és folyadékbevitel), ennek hatástalansága esetén epiduralis sajátvér-injekció, epiduralis fibrinragasztó-injektálás, illetve sebészi terápia jöhet szóba. Orv Hetil. 2021; 162(7): 246–251. Summary. Spontaneous intracranial hypotension, the classic feature of which is orthostatic headache, is most commonly caused by a cerebrospinal fluid leakage at the level of the spinal canal, in most cases at the thoracic level or cervicothoracic junction. Underlying connective tissue disorders, minor trauma, degenerative spinal diseases may play a role in the development of cerebrospinal fluid leaks. Traction on pain-sensitive intracranial and meningeal structures, particularly sensory nerves and bridging veins, may play a role in the development of orthostatic headache. In the case of patients with classic orthostatic headache, the possibility of spontaneous intracranial hypotension should be considered, and if suspected, brain magnetic resonance imaging (MRI) with gadolinium and additional spine MRI are recommended. Diffuse, non-nodular, intense, thick dural enhancement, subdural effusions, engorgement of cerebral venous sinuses, sagging of the brain are typical features on brain MRI, which, however, remain normal in up to 20 percent of patients with spontaneous intracranial hypotension. Unfortunately, no randomized clinical trials have evaluated the effectiveness of the various treatment strategies and no definitive treatment protocols have been established. In clinical practice, the first-line treatment of spontaneous intracranial hypotension is conservative (bed rest, caffeine and fluid intake). If conservative therapy is not effective, epidural blood patch, epidural fibrin glue, or surgical repair should be considered. Orv Hetil. 2021; 162(7): 246–251.

scholarly journals The importance of cephaliatric anamnesis in the diagnosis and early treatment of spontaneous intracranial hypotension: an experience told in a case report

2021 ◽  
Author(s):  
Juliana Magalhães Leite ◽  
Rafael de Souza Andrade ◽  
Thaís Magalhães Lima Leite ◽  
Fernando de Paiva Melo Neto ◽  
Vanessa Barreto Esteves
Keyword(s):  
Case Report ◽  
Early Treatment ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Orthostatic Headache ◽  
Neck Stiffness ◽  
Blood Patch ◽  
Csf Leakage ◽  
Spine Mri ◽  
Csf Leaks

Introduction: Spontaneous intracranial hypotension (SIH) is a rare syndrome, still underdiagnosed. It manifests with orthostatic headache and improves with decubitus, and may present nausea, vomiting, diplopia, vestibular and auditory symptoms. The main cause of SIH is spontaneous CSF leaks usually in the cervicothoracic transition. Case report: RSA, male, 36 years, he presented holocranial headache triggered in the orthostatic position and decubitus improvement associated with nausea. He denied visual complaints, fever, trauma or invasive procedures. Neurological examination: discrete neck stiffness, fundoscopy and others exams without abnormalities. Brain and cervical spine MRI, also venous AngioMRI were normal. Dorsal spine MRI with extradural collection. Arterial AngioMRI with 2,50x2,0mm aneurysmatic dilation in the right supraclinoid internal carotid artery. Opening pressure of CSF 6cmH2 O. Analgesia, decubitus rest and parsimonious hydration were performed. In cisternoscintigraphy, CSF leakage into the extradural space at the level of D3/D4 and D4/D5 on the left, delay in the rise of the tracer for brain convexities in 24 hours images, suggestive of CSF hypotension. Blood patch guided by radioscopy was performed, with improvement after 2 weeks of the 3rd procedure. Conclusion: Knowing the types of headache and its etiologies is essential to orientate diagnosis and treatment, avoiding unnecessary exams. In this case report, the microaneurysm found did not justify the complaint of orthostatic headache. The rapid diagnosis of spontaneous CSF leaks provided early treatment avoiding complications such as subdural hematomas, cerebral venous thrombosis, pituitary dysfunction.

Lumbar epidural blood patch: effectiveness on orthostatic headache and MRI predictive factors in 101 consecutive patients affected by spontaneous intracranial hypotension

2020 ◽  
Vol 132 (3) ◽  
pp. 809-817
Author(s):  
Vincenzo Levi ◽  
Nicola Ernesto Di Laurenzio ◽  
Andrea Franzini ◽  
Irene Tramacere ◽  
Alessandra Erbetta ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Overall Response Rate ◽  
Epidural Blood Patch ◽  
Response Rate ◽  
Spontaneous Intracranial Hypotension ◽  
Orthostatic Headache ◽  
Good Outcome ◽  
Vas Score ◽  
Blood Patch

OBJECTIVEAlthough epidural blood patch (EBP) is considered the gold-standard treatment for drug-resistant orthostatic headache in spontaneous intracranial hypotension (SIH), no clear evidence exists regarding the best administration method of this technique (blind vs target procedures). The aim of this study was to assess the long-term efficacy of blind lumbar EBP and predictors on preoperative MRI of good outcome.METHODSLumbar EBP was performed by injecting 10 ml of autologous venous blood, fibrin glue, and contrast medium in 101 consecutive patients affected by SIH and orthostatic headache. Visual analog scale (VAS) scores for headache were recorded preoperatively, at 48 hours and 6 months after the procedure, and by telephone interview in July 2017. Patients were defined as good responders if a VAS score reduction of at least 50% was achieved within 48 hours of the procedure and lasted for at least 6 months. Finally, common radiological SIH findings were correlated with clinical outcomes.RESULTSThe median follow-up was 60 months (range 8–135 months); 140 lumbar EBPs were performed without complications. The baseline VAS score was 8.7 ± 1.3, while the mean VAS score after the first EBP procedure was 3.5 ± 2.2 (p < 0.001). The overall response rate at the 6-month follow-up was 68.3% (mean VAS score 2.5 ± 2.4, p < 0.001). Symptoms recurred in 32 patients (31.7%). These patients underwent a second procedure, with a response rate at the 6-month follow-up of 78.1%. Seven patients (6.9%) did not improve after a third procedure and remained symptomatic. The overall response rate at the last follow-up was 89.1% with a mean VAS score of 2.7 ± 2.3 (p < 0.001). The only MRI predictors of good outcome were location of the iter > 2 mm below the incisural line (p < 0.05) and a pontomesencephalic angle (PMA) < 40° (p < 0.05).CONCLUSIONSLumbar EBP may be considered safe and effective in cases of drug-refractory SIH. The presence of a preprocedural PMA < 40° and location of the iter > 2 mm below the incisural line were the most significant predictors of good outcome. Randomized prospective clinical trials comparing lumbar with targeted EBP are warranted to validate these results.

scholarly journals Comparisons of clinical characteristics, brain MRI findings, and responses to epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache: retrospective study

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Gha-Hyun Lee ◽  
Jiyoung Kim ◽  
Hyun-Woo Kim ◽  
Jae Wook Cho
Keyword(s):  
Intracranial Hypotension ◽  
Dural Puncture ◽  
Epidural Blood Patch ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
Vein Of Galen ◽  
Mri Findings ◽  
Post Dural Puncture Headache ◽  
Straight Sinus ◽  
Blood Patch

Abstract Background Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment. Methods We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus). Results A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02). Conclusions Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

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