Brain volume changes in spontaneous intracranial hypotension: Revisiting the Monro-Kellie doctrine

Objectives In the application of the Monro-Kellie doctrine in spontaneous intracranial hypotension, the brain tissue volume is generally considered as a fixed constant. Traditionally, cerebral venous dilation is thought to compensate for decreased cerebrospinal fluid. However, whether brain tissue volume is invariable has not yet been explored. The objective of this study is to evaluate whether brain tissue volume is fixed or variable in spontaneous intracranial hypotension patients using automatic quantitative methods. Methods This retrospective and longitudinal study analyzed spontaneous intracranial hypotension patients between 1 January 2007 and 31 July 2015. Voxel-based morphometry was used to examine brain volume changes during and after the resolution of spontaneous intracranial hypotension. Brain structure volume was analyzed using Statistical Parametric Mapping version 12 and FMRIB Software Library v6.0. Post-treatment neuroimages were used as surrogate baseline measures. Results Forty-four patients with spontaneous intracranial hypotension were analyzed (mean [standard deviation] age, 37.8 [8.5] years; 32 female and 12 male). The whole brain tissue volume was decreased during spontaneous intracranial hypotension compared to follow-up (1180.3 [103.5] mL vs. 1190.4 [93.1] mL, difference: −10.1 mL [95% confidence interval: −18.4 to −1.8 mL], p = 0.019). In addition, ventricular cerebrospinal fluid volume was decreased during spontaneous intracranial hypotension compared to follow-up (15.8 [6.1] mL vs. 18.9 [6.9] mL, difference: −3.2 mL [95% confidence interval: −4.5 to −1.8 mL], p < 0.001). Longer anterior epidural cerebrospinal fluid collections, as measured by number of vertebral segments, were associated with greater reduction of ventricular cerebrospinal fluid volume (Pearson’s r = −0.32, p = 0.036). Conclusion The current study found the brain tissue volume and ventricular cerebrospinal fluid are decreased in spontaneous intracranial hypotension patients. The change in ventricular cerebrospinal fluid volume, but not brain tissue volume change, was associated with the severity of spinal cerebrospinal fluid leakage. These results challenge the assumption that brain tissue volume is a fixed constant.

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Acute reduction of cerebrospinal fluid volume prior to spinal anesthesia: implications for sensory block extent

Minerva Anestesiologica ◽

10.23736/s0375-9393.20.14138-5 ◽

2020 ◽

Vol 86 (6) ◽

Author(s):

Martin F. Bjurström ◽

Niklas Mattsson ◽

Andreas Harsten ◽

Nicholas Dietz ◽

Mikael Bodelsson

Keyword(s):

Cerebrospinal Fluid ◽

Spinal Anesthesia ◽

Sensory Block ◽

Fluid Volume ◽

Cerebrospinal Fluid Volume

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690 Intracranial Hypotension Due to CSF Leak Secondary to Ventral Thoracic Osteophyte Complex: Resolution After Transdural Thoracic Discectomy and Dural Repair

British Journal of Surgery ◽

10.1093/bjs/znab134.313 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

B Kewlani ◽

I Hussain ◽

J Greenfield

Keyword(s):

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Bed Rest ◽

Structural Defects ◽

Csf Leak ◽

History Of ◽

Surgical Cure ◽

Thoracic Discectomy ◽

Herniated Discs

Abstract The hallmark symptom of spontaneous intracranial hypotension (SIH) is orthostatic headaches which manifests secondary to cerebrospinal fluid (CSF) hypovolaemia. Well-recognised aetiologies include trauma which includes procedures such as lumbar punctures and spinal surgery. More recently, structural defects such as bony osteophytes and calcified or herniated discs have been attributed to mechanically compromising dural integrity consequently resulting in CSF leak and symptom manifestation. A thorough literature review noted only a handful of such cases. We report the case of a thirty-two-year-old Asian female who presented with a one-month history of new-onset progressively worsening orthostatic headaches. Workup included MRI of the thoracic spine which revealed an epidural collection of CSF consequently prompting a dynamic CT-myelogram of the spine which not only helped to confirm severe cerebral hypotension but also suggested the underlying cause as being a dorsally projecting osteophyte-complex at level T2-3. Conservative and medical management including bed rest, analgesia, mechanical compression, and epidural blood patches failed to alleviate symptoms and a permanent surgical cure was eventually sought. The surgery involved T2-T3 laminectomy and osteophytectomy and at a 3-month follow-up, complete resolution of symptoms was noted.

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Case report: spontaneous intracranial hypotension in association with the presence of a false localizing C1-C2 cerebrospinal fluid leak

Surgical Neurology ◽

10.1016/j.surneu.2007.05.037 ◽

2008 ◽

Vol 70 (5) ◽

pp. 539-543 ◽

Cited By ~ 8

Author(s):

Jonathan T. Morgan ◽

Alexander J. Scumpia ◽

Alan A. Johnson ◽

Steven J. Schneider

Keyword(s):

Cerebrospinal Fluid ◽

Case Report ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Cerebrospinal Fluid Leak ◽

Fluid Leak

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Comparison of the radioisotope cisternography findings of spontaneous intracranial hypotension and iatrogenic cerebrospinal fluid leakage focusing on chronological changes

Cephalalgia ◽

10.1177/0333102412459571 ◽

2012 ◽

Vol 32 (15) ◽

pp. 1131-1139 ◽

Cited By ~ 7

Author(s):

Keita Sakurai ◽

Minoru Nishio ◽

Kazuo Yamada ◽

Masashi Shimohira ◽

Yoshiyuki Ozawa ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Cerebrospinal Fluid Leakage ◽

Fluid Leakage

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Torticollis as an Initial Manifestation of a Seronegative Demyelinating Disorder in a Child: A Case Report

Journal of Pediatric Neurology ◽

10.1055/s-0041-1736599 ◽

2021 ◽

Author(s):

Sandesh Kini ◽

Yellanthoor Ramesh Bhat ◽

Lakshmikanth Halegubbi Karegowda

Keyword(s):

Multiple Sclerosis ◽

Cerebrospinal Fluid ◽

Case Report ◽

Demyelinating Disease ◽

Oligoclonal Bands ◽

Initial Manifestation ◽

Demyelinating Disorder ◽

The Brain

AbstractTorticollis refers to a condition in which the head is persistently tilted to one side, sometimes associated with pain. Torticollis in a child can be congenital or acquired. Torticollis as an initial manifestation of an underlying demyelinating syndrome is quite rare in children. Here, we report a 7-year-old girl who presented with persistent torticollis. Neuroimaging of the brain revealed features of a demyelinating disease. Further studies did not show any evidence of multiple sclerosis. Cerebrospinal fluid was negative for antiaquaporin-4 antibodies, antimyelin oligodendrocyte glycoprotein antibodies, and oligoclonal bands. A seronegative demyelinating disorder was considered. She was treated with pulsed methylprednisolone therapy. She responded well to steroids with no progression of illness during follow-up. Torticollis was partially improved.

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Clinical Outcomes Following Surgical Ligation of Cerebrospinal Fluid-Venous Fistula in Patients With Spontaneous Intracranial Hypotension: A Prospective Case Series

Operative Neurosurgery ◽

10.1093/ons/opz134 ◽

2019 ◽

Cited By ~ 1

Author(s):

Timothy Y Wang ◽

Isaac O Karikari ◽

Timothy J Amrhein ◽

Linda Gray ◽

Peter G Kranz

Keyword(s):

Cerebrospinal Fluid ◽

Clinical Outcomes ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Case Series ◽

Surgical Ligation ◽

Prospective Case Series ◽

Venous Fistula

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A case of complicated cerebral toxocariasis in a 4-year old child

Helminthologia ◽

10.2478/s11687-008-0034-z ◽

2008 ◽

Vol 45 (4) ◽

pp. 169-172 ◽

Cited By ~ 7

Author(s):

J. Kinčeková ◽

P. Bánovčin ◽

M. Fedor ◽

P. Dubinský ◽

H. Poláček ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Primary Infection ◽

Diagnostic Method ◽

Morphological Changes ◽

Final Diagnosis ◽

High Serum ◽

Focal Lesions ◽

Almost All ◽

The Brain

AbstractWe report the case of a 4-year-old boy suffering from a cerebral form of toxocariasis. High serum titres of anti-Toxocara antibodies indicated that the primary infection was induced by a high number of Toxocara eggs and that the larvae did not penetrate to cerebrospinal fluid due to the hematoencephalic barrier. MRI of the patient’s brain showed multiple focal lesions spread diffusely in almost all parts of the brain, predominantly paraventricularly. These might be eosinophil-rich granulomatous infiltrates enclosing larvae. Extensive morphological changes were the cause of serious neurological symptoms, most of them being reversible after follow-up therapy. Radiology proved to be useful diagnostic method, but the specific serological assessment had a key role for the final diagnosis. In conclusion, diagnosis of this patient was intracranial primary Toxocara infection with central quadruparesis and parainfective myocarditis.

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Surgical treatment of spontaneous spinal cerebrospinal fluid leaks

Journal of Neurosurgery ◽

10.3171/jns.1998.88.2.0243 ◽

1998 ◽

Vol 88 (2) ◽

pp. 243-246 ◽

Cited By ~ 150

Author(s):

Wouter I. Schievink ◽

Vittorio M. Morreale ◽

John L. D. Atkinson ◽

Fredric B. Meyer ◽

David G. Piepgras ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Surgical Treatment ◽

Intracranial Hypotension ◽

Csf Leak ◽

Preoperative Imaging ◽

Content Type ◽

Surgical Exploration ◽

Fine Print ◽

Csf Leaks

Object. Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. Methods. Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22–61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. Conclusions. All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3–58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

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