scholarly journals Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment

2021 ◽  
Vol 36 (1) ◽  
Author(s):  
Efthalia Angelopoulou ◽  
Eirini Pantou ◽  
Georgios Zacharis ◽  
Michail Rentzos ◽  
Leonidas Stefanis ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Randomized Clinical Trials ◽  
Traumatic Event ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
High Dose ◽  
Trauma History ◽  
Blood Patch ◽  
Csf Leakage ◽  
Literature Evidence

Abstract Background Spontaneous intracranial hypotension (SIH) is characterized by positional headache caused by low CSF pressure, without any major traumatic event. Optimal treatment is still debated; epidural blood patch (EBP) is usually used after unsuccessful conservative treatment with variable efficacy and potentially severe complications. Although steroids have been reported to be beneficial, their effectiveness is still controversial, and more clinical evidence is needed. Case presentation A 37-year-old woman was admitted to the neurology department due to severe orthostatic headache with nausea over the last 5 days. No trauma history or spinal manipulation were mentioned. On arrival, neurological examination, brain CT, and laboratory investigation were normal. Intracranial hypotension was clinically suspected, and lumbar puncture revealed low opening pressure. Brain MRI demonstrated pachymeningeal gadolinium enhancement and distended and rounded dural venous sinuses, while cervicothoracic spine MRI revealed thoracic CSF leakage, leading to SIH diagnosis. The patient was treated with high-dose intravenous methylprednisolone, with complete clinical resolution within 24 h. Conclusions Our case, combined with literature evidence, supports the high-dose intravenous corticosteroids as a reasonable treatment option in selected cases, before trying EBP or surgical repair. Randomized clinical trials are needed, in order to optimize SIH patients’ outcomes.

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.

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.

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.

Spontaneous intracranial hypotension syndrome: a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients

2010 ◽  
Vol 112 (2) ◽  
pp. 300-306 ◽  
Author(s):  
Angelo Franzini ◽  
Giuseppe Messina ◽  
Vittoria Nazzi ◽  
Eliana Mea ◽  
Massimo Leone ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Clinical Symptoms ◽  
Autologous Blood ◽  
Spontaneous Intracranial Hypotension ◽  
Drainage System ◽  
Venous Drainage ◽  
Clinical Results ◽  
Epidural Block ◽  
Blood Patch ◽  
Csf Leakage

Object Spontaneous intracranial hypotension (SIH) is a potentially serious pathological syndrome consisting of specific symptoms and neuroradiological signs that can sometimes be used to assess the efficacy of the treatment. In this paper the authors report a series of 28 patients with this syndrome who were all treated with an epidural blood patch at the authors' institution. The authors propose a novel physiopathological theory of SIH based on some anatomical considerations about the spinal venous drainage system. Methods Between January 1993 and January 2007, the authors treated 28 patients in whom SIH had been diagnosed. Twenty-seven of the 28 patients presented with the typical findings of SIH on brain MR imaging (dural enhancement and thickening subdural collections, caudal displacement of cerebellar tonsils, and reduction in height of suprachiasmatic cisterns). The sites of the patients' neuroradiologically suspected CSF leakage were different, but the blood patch procedure was performed at the lumbar level in all patients. The patients were then assessed at 3-month and 1- and 3-year follow-up visits. At the last visit (although only available for 11 patients) 83.3% of patients were completely free from clinical symptoms and 8.3% complained of sporadic orthostatic headache. Results The authors think that in the so-called SIH syndrome, the dural leak, even in those cases in which it can be clearly identified on neuroradiological examinations, is not the cause of the disease but the effect of the epidural hypotension maintained by the inferior cava vein outflow to the heart. The goal of their blood patch procedure (a sort of epidural block obtained using autologous blood and fibrin glue at the L1–2 level) is not to seal CSF leaks, but instead to help in reversing the CSF-blood gradient within the epidural space along the entire cord. Conclusions The authors' procedure seems to lead to good and long-lasting clinical results.

scholarly journals Targeted Epidural Blood Patch Treatment for Refractory Spontaneous Intracranial Hypotension in China

2017 ◽  
Vol 79 (03) ◽  
pp. 217-223 ◽  
Author(s):  
Fei-Fang He ◽  
Li Li ◽  
Min-Jun Liu ◽  
Tai-Di Zhong ◽  
Qiao-Wei Zhang ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Persistent Symptoms ◽  
Ionic Contrast ◽  
Blood Patch ◽  
Csf Leakage ◽  
Whole Spine ◽  
Mr Myelography ◽  
Csf Leaks

Objective An epidural blood patch (EBP) is the mainstay of treatment for refractory spontaneous intracranial hypotension (SIH). We evaluated the treatment efficacy of targeted EBP in refractory SIH. Methods All patients underwent brain magnetic resonance imaging (MRI) with contrast and heavily T2-weighted spine MRI. Whole spine computed tomography (CT) myelography with non-ionic contrast was performed in 46 patients, and whole spine MR myelography with intrathecal gadolinium was performed in 119 patients. Targeted EBPs were placed in the prone position one or two vertebral levels below the cerebrospinal fluid (CSF) leaks. Repeat EBPs were offered at 1-week intervals to patients with persistent symptoms, continued CSF leakage, or with multiple leakage sites. Results Brain MRIs showed pachymeningeal enhancement in 127 patients and subdural hematomas in 32 patients. One hundred fifty-two patients had CSF leakages on heavily T2-weighted spine MRIs. CSF leaks were also detected on CT and MR myelography in 43 and 111 patients, respectively. Good recovery was achieved in all patients after targeted EBP. No serious complications occurred in patients treated with targeted EBP during the 1 to 7 years of follow-up. Conclusions Targeted and repeat EBPs are rational choices for treatment of refractory SIH caused by CSF leakage.

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.

scholarly journals Spontaneous Intracranial Hypotension and the durability of Epidural Blood Patch

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Ali Hazama ◽  
Lori John ◽  
Alexander E Braley ◽  
Lawrence S Chin ◽  
Satish Krishnamurthy
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Symptomatic Relief ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
Brain Magnetic Resonance Imaging ◽  
Definitive Treatment ◽  
Csf Leak ◽  
Persistent Symptoms ◽  
Blood Patch

Abstract INTRODUCTION Spontaneous Intracranial Hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate recent efficacy and outcomes of EBP for SIH at our institution. We also sought to explore the viability of repeat blood patches for patients whose symptoms persisted or recurred. METHODS A total of 23 patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018. All patients underwent brain magnetic resonance imaging (MRI) with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBPs were placed at 1-2 vertebral levels below identified or suspected areas of leak. Patients were seen within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 mo following clinical relief of symptoms. RESULTS 22/23 (95.7%) patients presented with complaints of orthostatic headache, 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningial enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, 5/23 (21.7%) patients received repeat EBPs for persistent symptoms will all achieving relief after repeat EBP. About 5/12 (41.7%) patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient was 21.7 mL. In total, 18/23 (78.2%) patients are currently asymptomatic with regards to their SIH. Mean follow-up in this cohort was 2.6 yr. CONCLUSION EBP is a viable option for the treatment of SIH caused by CSF leak. Repeat epidural blood patch is reasonable in cases of recurrent symptoms.

Procedural predictors of epidural blood patch efficacy in spontaneous intracranial hypotension

2019 ◽  
Vol 44 (2) ◽  
pp. 212-220 ◽  
Author(s):  
Gabriel L Pagani-Estévez ◽  
Jeremy K Cutsforth-Gregory ◽  
Jonathan M Morris ◽  
Bahram Mokri ◽  
David G Piepgras ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
Case Series ◽  
Mri Findings ◽  
Retrospective Case ◽  
Volume Number ◽  
Institutional Review ◽  
Blood Patch

Background and objectiveEpidural blood patch (EBP) is a safe and effective treatment for spontaneous intracranial hypotension (SIH), but clinical and procedural variables that predict EBP efficacy remain nebulous.MethodsThis study is an institutional review board-approved retrospective case series with dichotomized EBP efficacy defined at 3 months. The study included 202 patients receiving 604 EBPs; iatrogenic cerebrospinal fluid leaks were excluded.ResultsOf the EBPs, 473 (78%) were single-level, 349 (58%) lumbar, 75 (12%) bilevel, and 56 (9%) multilevel (≥3 levels). Higher volume (OR 1.64; p<0.0001), bilevel (3.17, 1.91–5.27; p<0.0001), and multilevel (117.3, 28.04–490.67; p<0.0001) EBP strategies predicted greater efficacy. Only volume (1.64, 1.47–1.87; p<0.0001) remained significant in multivariate analysis. Site-directed patches were more effective than non-targeted patches (8.35, 0.97–72.1; p=0.033). Lower thoracic plus lumbar was the most successful bilevel strategy, lasting for a median of 74 (3–187) days.ConclusionsIn this large cohort of EBP in SIH, volume, number of spinal levels injected, and site-directed strategies significantly correlated with greater likelihood of first EBP efficacy. Volume and leak site coverage likely explain the increased efficacy with bilevel and multilevel patches. In patients with cryptogenic leak site, and either moderate disability, negative prognostic brain MRI findings for successful EBP, or failed previous lumbar EBP, a low thoracic plus lumbar bilevel EBP strategy is recommended. Multilevel EBP incorporating transforaminal administration and fibrin glue should be considered in patients refractory to bilevel EBP. An algorithmic approach to treating SIH is proposed.

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.

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