Pearls & Oy-sters: Dural defect repair as treatment for refractory headache from cerebrospinal fluid leak

Headache occurs after dural puncture in about 1%–25% of children who undergo the procedure—a rate similar to that seen in adults. Persistence of post–dural puncture headache in spite of bed rest, increased fluid intake, and epidural blood patch treatment, however, is rare. The authors reviewed the medical records and imaging studies of all patients 19 years of age or younger who they evaluated between 2001 and 2010 for intracranial hypotension, and they identified 8 children who had persistent post–dural puncture headache despite maximal medical treatment and placement of epidural blood patches. A CSF leak could be demonstrated radiologically and treated surgically in 3 of these patients, and the authors report these 3 cases. The patients were 2 girls (ages 14 and 16 years) who had undergone lumbar puncture for evaluation of headache and fever and 1 boy (age 13 years) who had undergone placement of a lumboperitoneal shunt using a Tuohy needle for treatment of pseudotumor cerebri. The boy also had undergone a laminectomy and exploration of the posterior dural sac, but no CSF leak could be identified. All 3 patients presented with new-onset orthostatic headaches, and in all 3 cases MRI demonstrated a large ventral lumbar or thoracolumbar CSF collection. Conventional myelography or digital subtraction myelography revealed a ventral dural defect at L2–3 requiring surgical repair. Through a posterior transdural approach, the dural defect was repaired using 6-0 Prolene sutures and a dural substitute. Postoperative recovery was uneventful, with complete resolution of orthostatic headache and of the ventral cerebrospinal fluid leak on MRI. The authors conclude that persistent postdural puncture headache requiring surgical repair is rare in children. They note that the CSF leak may be located ventrally and may require conventional or digital subtraction myelography for exact localization and that transdural repair is safe and effective in eliminating the headaches.

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Management of cerebrospinal fluid leak after surgical removal of pituitary adenomas

Medicina ◽

10.3390/medicina44040039 ◽

2008 ◽

Vol 44 (4) ◽

pp. 302 ◽

Cited By ~ 33

Author(s):

Arimantas Tamašauskas ◽

Kęstutis Šinkūnas ◽

Wolfgang Draf ◽

Vytenis Deltuva ◽

Algimantas Matukevičius ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Sella Turcica ◽

Cerebrospinal Fluid Leak ◽

Surgical Removal ◽

Dural Defect ◽

Sphenoidal Sinus ◽

Autologous Fat ◽

Csf Leakage ◽

Dural Defects ◽

Fluid Leak

Objectives. The aim of the study was to evaluate the frequency and the causes of the intra- and postoperative cerebrospinal fluid (CSF) leaks and to discuss the sella closure methods. Methods. During the period from 1995 to 2005, 313 patients underwent 356 transsphenoidal operations for pituitary adenoma. Microadenoma was found in 80 (22.5%) cases, and in 276 (77.5%) cases, macroadenoma was removed. Two different methods to close the sella were used. The first one consisted packing the sella turcica and sphenoidal sinus with autologous fat and restoring the defect of sella turcica with autologous bone. In more resent practice, the regenerated oxidized cellulose (Surgicel®) and collagen sponge with human fibrin (TachoSil®) were used to cover the sella membrane defect, followed by packing the sella with autologous fat and covering the dural defect with Surgicel® and TachoSil®. Results. Adenoma was totally removed in 198 (55.6%) cases out of 356. Microadenoma was totally removed in 91.3% and macroadenoma in 45.3% of cases, respectively. Postoperative complications were noted in 40 (11.2%) patients. Two (0.6%) patients died after surgery. Intraoperative CSF leakage was observed in 58 (16.3%) cases. Postoperative CSF leakages were observed in 3 cases, when the method of packing the sella with just autologous fat was used, whereas in 29 cases when the sella fat packing was used together with Surgicel® and TachoSil® to cover the sella membrane and dural defects, no postoperative CSF leakages were observed. Conclusions. The technique of covering the sella membrane and dural defects with Surgicel® and TachoSil® in the presence of intraoperative CSF leakage appeared to be the most reliable one, as no postoperative CSF leakage applying this technique has been observed.

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Cranial Neuropathy Due to Intradural Disc Herniation

Neurosurgery ◽

10.1227/neu.0000000000000315 ◽

2014 ◽

Vol 74 (5) ◽

pp. E561-E565 ◽

Cited By ~ 6

Author(s):

Benjamin I. Rapoport ◽

Roger Hartl ◽

Theodore H. Schwartz

Keyword(s):

Cerebrospinal Fluid ◽

Disc Herniation ◽

Intracranial Hypotension ◽

Cerebrospinal Fluid Leak ◽

Herniated Disc ◽

Cranial Neuropathy ◽

Dural Defect ◽

Intradural Disc Herniation ◽

Intradural Space ◽

Fluid Leak

Abstract BACKGROUND AND IMPORTANCE: Herniated intervertebral disc fragments rarely penetrate the thecal sac, and intracranial hypotension attributable to such penetrating fragments is even more unusual. We describe the first reported case of a cranial neuropathy due to intradural herniation of a disc fragment, in which intracranial hypotension from a resulting cerebrospinal fluid leak caused bilateral abducens palsies. CLINICAL PRESENTATION: A 45-year-old man presented with a positional headache after having experienced a “popping” sensation in his back while lifting a heavy object. He also reported blurred vision and was noted to have lateral gaze palsies bilaterally. Magnetic resonance imaging (MRI) of the brain revealed bilateral subdural collections, abnormal pachymeningeal enhancement, and cerebellar tonsillar herniation, suggesting intracranial hypotension. T2-weighted MRI of the spine revealed extrusion of the T12-L1 disc and suggested the presence of a disc fragment in the intradural space, displacing the caudal nerve roots. A myelogram demonstrated a filling defect extending into the subarachnoid space adjacent to the disc herniation, consistent with a free disc fragment in the intradural space. A diagnosis of intracranial hypotension due to a cerebrospinal fluid leak resulting from an intradural herniated disc was made. The diagnosis was confirmed intraoperatively. CONCLUSION: Surgical removal of the herniated disc fragment and repair of the dural defect resulted in complete resolution of the cranial neuropathy. This rare etiology of a cranial neuropathy, arising from pathology in the thoracolumbar spine, illustrates the clinical teaching that the sixth cranial nerve is highly sensitive to deformation induced by intracranial hypotension.

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