Severe acute orthostatic headache: spontaneous intracranial hypotension (SIH)

2021 ◽  
Vol 14 (6) ◽  
pp. e243179
Author(s):  
Pushpendra Nath Renjen ◽  
Dinesh Mohan Chaudhari ◽  
Nidhi Goyal ◽  
Kamal Ahmed
Keyword(s):  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Signs And Symptoms ◽  
Csf Leak ◽  
Lumbosacral Spine ◽  
Ct Guided ◽  
Mri Features ◽  
Blood Patch ◽  
Csf Leakage ◽  
Underlying Mechanisms

The most common cause of spontaneous intracranial hypotension headache is a cerebrospinal fluid (CSF) leakage, but the underlying mechanisms remain unknown. Intracranial hypotension is characterised by diffuse pachymeningeal enhancement on cranial MRI features, low CSF pressure and orthostatic headaches mostly caused by the dural puncture. We report a 31-year-old woman who presented to our services with reports of continuous severe bifrontal headache, which increased on sitting up and resolved on lying down. MRI of the cervical and lumbosacral spine showed signs of CSF leak; hence, patient was diagnosed with spontaneous intracranial hypotension headache. A CT-guided epidural blood patch was done at L4–5 with fibrin glue injected at the site of leak. The patient’s signs and symptoms improved after the procedure.

scholarly journals Targeted CT-Guided Epidural Blood Patch for Treatment of Spontaneous Intracranial Hypotension Due to Calcified Intradural Thoracic Disc Herniation

2013 ◽  
Vol 19 (1) ◽  
pp. 121-126 ◽  
Author(s):  
V. Agarwal ◽  
G. Sreedher ◽  
W.E. Rothfus
Keyword(s):  
Disc Herniation ◽  
Epidural Space ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Fluoroscopic Guidance ◽  
Ct Guided ◽  
Blood Patch ◽  
Disc Herniations

Calcified thoracic intradural disc herniations have recently been reported as a cause of spontaneous intracranial hypotension (SIH). We report successful treatment of SIH with a targeted CT-guided epidural blood patch. A 57-year-old man presented to the emergency department with a two-week history of progressively debilitating headache. CT and MRI of the brain showed findings consistent with intracranial hypotension and MRI of the spine showed findings consistent with CSF leak. Subsequent CT myelogram of the thoracic spine confirmed the presence of CSF leak and calcified disc herniations at the T6-7, T7-8 and T8-9 levels indenting the ventral dura and spinal cord. The calcified disc herniation at T6-7 had an intradural component and was therefore the most likely site of the CSF leak. Under CT fluoroscopic guidance, a 20-gauge Tuohy needle was progressively advanced into the dorsal epidural space at T6-7. After confirmation of needle tip position, approximately 18cc of the patient's own blood was sterilely removed from an arm vein and slowly re-injected into the dorsal epidural space. With satisfactory achievement of clot formation, the procedure was terminated. The patient tolerated the procedure well. The next morning, his symptoms had completely resolved and he was neurologically intact. At five-week follow up, he was symptom-free. Targeted epidural blood patch at the site of presumed CSF leak can be carried out in a safe and effective manner using CT fluoroscopic guidance and can be an effective alternative to open surgical management in selected patients.

scholarly journals Spontaneous Intracranial Hypotension Treated with a Targeted CT-Guided Epidural Blood Patch

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
Inês Correia ◽  
Inês Brás Marques ◽  
Rogério Ferreira ◽  
Miguel Cordeiro ◽  
Lívia Sousa
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Complete Recovery ◽  
Csf Leak ◽  
Ct Guided ◽  
Blood Patch ◽  
History Of ◽  
Persistent Headache ◽  
Csf Leaks

Spontaneous intracranial hypotension (SIH) is an important cause of new daily persistent headache. It is thought to be due to spontaneous spinal cerebrospinal fluid (CSF) leaks, which probably have a multifactorial etiology. The classic manifestation of SIH is an orthostatic headache, but other neurological symptoms may be present. An epidural blood patch is thought to be the most effective treatment, but a blind infusion may be ineffective. We describe the case of a young man who developed an acute severe headache, with pain worsening when assuming an upright posture and relief gained with recumbency. No history of previous headache, recent cranial or cervical trauma, or invasive procedures was reported. Magnetic resonance imaging showed pachymeningeal enhancement and other features consistent with SIH and pointed towards a cervical CSF leak site. After failure of conservative treatment, a targeted computer tomography-guided EBP was performed, with complete recovery.

scholarly journals Interdisciplinary Diagnosis and Management of Cerebrospinal Fluid Leakage Due to a Meningeal Diverticulum: a Case Report

2020 ◽  
Author(s):  
Christoph Gregor Trumm ◽  
Robert Forbrig
Keyword(s):  
Cerebrospinal Fluid ◽  
False Positive ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Cerebrospinal Fluid Leakage ◽  
Ct Guided ◽  
Fluid Leakage ◽  
Blood Patch ◽  
Csf Leakage ◽  
Spinal Epidural

AbstractCerebrospinal fluid leakage through meningeal diverticula represents a diagnostic and therapeutic challenge comparatively rarely encountered in the interdisciplinary management of spontaneous intracranial hypotension (SIH). Several false-positive CSF leakage signs may be observed during the imaging work-up of SIH. A 27-year-old female with orthostatic headache showing marked spinal epidural CSF collections and MRI signs of intracranial hypotension underwent a blind and CT-guided epidural blood patch (EBP) of a pathological T9/10 meningeal diverticulum (MD), detected by dynamic CT myelography (dCTM). After initial good imaging and symptomatic improvement, recurrent symptoms and a large left-sided subdural hematoma required neurosurgical MD ligation, with persisting clinical success. The following aspects of this brief report are remarkable: added value of dCTM to synchronously detect true CSF leakage and false-positive CSF leakage signs, near-complete resolution of spinal epidural CSF collections after CT fluoroscopy–guided EBP, interdisciplinary diagnosis, and definite management of CSF leakage through an anomalous MD.

scholarly journals Typical MRI Features in Spontaneous Intracranial Hypotension: A Rare Cause of Headache

2012 ◽  
Vol 1 (1) ◽  
pp. 45-51
Author(s):  
N Hekha ◽  
CC Tchoyoson Lim
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Imaging Features ◽  
Postural Headache ◽  
Delay In Diagnosis ◽  
Mri Features ◽  
Blood Patch ◽  
Csf Leakage ◽  
Fluid Collections

Spontaneous CSF leakage from the spinal canal can give rise to spontaneous intracranial hypotension (SIH). Typically, these patients complain of orthostatic (postural) headache, have very low CSF pressure on lumbar puncture (LP) and usually respond to conservative treatment or by an epidural blood patch. The characteristic MRI features include subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperaemia and sagging of the cerebellar tonsils. Radiologists should recognize the typical clinical and imaging features of SIH and distinguish it from more sinister or malignant differential diagnosis, in order to prevent a delay in diagnosis or unnecessary surgical intervention, especially in resource-constrained situations in developing nations.DOI: http://dx.doi.org/10.3126/njr.v1i1.6324 Nepalese Journal of Radiology Vol.1(1): 45-51 

Spontaneous Intracranial Hypotension Treated with CT-guided Cervical Epidural Blood Patch - A case report -

2007 ◽  
Vol 52 (1) ◽  
pp. 115 ◽  
Author(s):  
Jin Hye Min ◽  
Young Soon Choi ◽  
Yong Ho Kim ◽  
Woo Kyung Lee ◽  
Yong Kyung Lee ◽  
...  
Keyword(s):  
Case Report ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Ct Guided ◽  
Blood Patch

Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

2012 ◽  
Vol 116 (4) ◽  
pp. 749-754 ◽  
Author(s):  
Wouter I. Schievink ◽  
Marc S. Schwartz ◽  
M. Marcel Maya ◽  
Franklin G. Moser ◽  
Todd D. Rozen
Keyword(s):  
Skull Base ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Spinal Imaging ◽  
Radiological Data ◽  
Single Instance ◽  
Csf Leakage ◽  
Csf Leaks

Object Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. Methods Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period. Results Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. Conclusions There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

scholarly journals Spontaneous Intracranial Hypotension Manifesting as a Unilateral Subdural Hematoma with a Marked Midline Shift

2015 ◽  
Vol 7 (1) ◽  
pp. 71-77 ◽  
Author(s):  
Joji Inamasu ◽  
Shigeta Moriya ◽  
Junpei Shibata ◽  
Tadashi Kumai ◽  
Yuichi Hirose
Keyword(s):  
Mental Status ◽  
Subdural Hematoma ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Altered Mental Status ◽  
Midline Shift ◽  
Hematoma Evacuation ◽  
Neurologic Deterioration ◽  
Blood Patch ◽  
Csf Leakage

Spontaneous intracranial hypotension (SIH) is a syndrome in which hypovolemia of the cerebrospinal fluid (CSF) results in various symptoms. Although its prognosis is usually benign, cases with a rapid neurologic deterioration resulting in an altered mental status have been reported. One of the characteristic radiographic findings in such cases is the presence of bilateral accumulation of subdural fluid (hematoma/hygroma). When SIH-related subdural hematoma is present only unilaterally with a concomitant midline shift, making an accurate diagnosis may be challenging, and inadvertent hematoma evacuation may result in further neurologic deterioration. We report a 58-year-old woman with an altered mental status who had visited a local hospital and in whom a brain CT showed a unilateral subdural hematoma with a marked midline shift. She was referred to our department because of her neurologic deterioration after hematoma evacuation. A CT myelography revealed a massive CSF leakage in the entire thoracic epidural space. She made a full neurologic recovery following blood patch therapy. Our case is unique and educational because the suspicion for SIH as an underlying cause of subdural hematoma is warranted in nongeriatric patients not only with bilateral but also unilateral lesions. An immediate search for CSF leakage may be important in cases with failed hematoma evacuation surgery.

scholarly journals Intracranial Hypotension for Anesthesiologists: What We Should Know

2019 ◽  
pp. 69-76
Author(s):  
Maria Eugenia Calvo
Keyword(s):  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Case Series ◽  
Low Flow ◽  
Csf Leak ◽  
Common Denominator ◽  
Invasive Treatment ◽  
Blood Patch ◽  
Mechanism Of Trauma ◽  
Csf Leaks

The common denominator of spontaneous intracranial hypotension (SIH), postsurgical cerebral spinal fluid (CSF) leaks, and postpuncture headache (PPH) is a decrease in CSF volume. The typical presentation is orthostatic headaches, but atypical headaches can be difficult to diagnose and challenging to treat. Management is based on clinical suspicion and characterization of the headache, followed by imaging (noninvasive or invasive). Treatment ranges from conservative to different modalities of epidural blood patches, fibrin glue injections, or surgical exploration and repair. We report 5 cases with great variation in clinical and radiological presentations. Two cases of SIH involved difficult diagnosis and treatment, 2 others featured postsurgical high-flow CSF leaks, and one case presented with a low-flow CSF leak that needed closer evaluation in relation to hardware manipulation. In all cases, recommendations for diagnosis and management of intracranial hypotension were followed, even though in 3 cases the mechanism of trauma was not related to spontaneous hypotension. All cases of headache were resolved. The actual recommendations for SIH are very effective for PPH and postsurgical CSF leaks. With this case series, we illustrate how anatomical and clinical considerations are paramount in choosing appropriate imaging modalities and clinical management. Key words: CSF leak, epidural blood patch, intracranial hypotension, postural headaches, subdural hematomas

Spontaneous Intracranial Hypotension and MRI

1998 ◽  
Vol 11 (2) ◽  
pp. 203-206
Author(s):  
I. Muras ◽  
A. Scuotto ◽  
M. Maisto ◽  
F.P. Bernini
Keyword(s):  
Intracranial Hypotension ◽  
Medical Condition ◽  
Spontaneous Intracranial Hypotension ◽  
Bed Rest ◽  
Csf Leak ◽  
Meningeal Enhancement ◽  
Csf Leakage ◽  
Downward Displacement ◽  
Fluid Collections ◽  
The Brain

Postural headache due to low intracranial pressure is a well-known entity and is most commonly encountered following lumbar puncture. It may occur as a consequence of a medical condition (dehydratation, uremia, etc.) but in some cases no precipitating event is apparent and the intracranial hypotension is believed to have developed spontaneously. In such cases the underlying cause of the syndrome is rarely established and treatment is non specific. We describe three patients with spontaneous intracranial hypotension examined with MRI of the brain. Women are more commonly affected than men in the third or fourth decades of life. Schaltenbrand (1938) proposed three mechanisms by which spontaneous intracranial hypotension may be explained: diminished CSF production; CSF hyperabsorption, CSF leakage. The defect causing a CSF leak usually remains obscure. Several cases of diffuse meningeal enhancement on MRI have recently been described, probably due to meningeal hyperaemia resulting from the low CSF pressure. Subdural fluid collections have also been detected as a result of rupture of bridging veins due to the decrease in CSF volume and downward displacement of the brain. In our cases, MRI showed a diffuse dural thickening, hyperintense in T2. Spontaneous intracranial hypotension is often a self-limiting disease, responding well to bed rest and a generous intake of oral or parenteral fluid and salt.

Headache attributed to spontaneous intracranial hypotension

2020 ◽  
pp. 346-355
Author(s):  
Farnaz Amoozegar ◽  
Esma Dilli ◽  
Rashmi B. Halker ◽  
Amaal J. Starling
Keyword(s):  
Intracranial Hypotension ◽  
Clinical Symptoms ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Non Invasive ◽  
Appropriate Treatment ◽  
Clinical Presentations ◽  
Blood Patch ◽  
Underlying Pathophysiology ◽  
Diagnostic Investigations

Spontaneous intracranial hypotension (SIH) caused by a spontaneous cerebrospinal fluid (CSF) leak, results in CSF hypovolaemia. Owing to the variety of clinical presentations and numerous possible diagnostic investigations, diagnosis and appropriate treatment remains challenging in many patients. Although the typical presentation of SIH is an orthostatic headache, the clinical spectrum includes a variety of headache types, focal neurological symptoms, and even spinal manifestations. The underlying pathophysiology of SIH varies depending on the clinical scenario. However, a deeper understanding of the pathophysiology has led to the recognition of risk factors and an explanation for clinical symptoms and abnormalities on diagnostic investigations. Multiple diagnostic investigations can be used to determine if a CSF leak is present or not. Magnetic resonance imaging of the head with and without contrast is sensitive and non-invasive. However, computed tomography myelography remains the study of choice to locate the site of the leak. The rate of flow of the CSF leak can pose a challenge to standard diagnostic investigations. To date, a large-volume blind epidural blood patch is the mainstay of treatment, although more targeted approaches are used for more refractory cases.

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