Novel hydrogel application in minimally invasive surgical approaches to spontaneous intracranial hypotension

The authors report 2 cases of orthostatic headaches associated with spontaneous intracranial hypotension (SIH) secondary to CSF leaks that were successfully treated with an alternative dural repair technique in which a tubular retractor system and a hydrogel dural sealant were used. The 2 patients, a 63-year-old man and a 45-year-old woman, presented with orthostatic headache associated with SIH secondary to suspected lumbar and lower cervical CSF leaks, respectively, as indicated by bony defects or epidural fluid collection. Epidural blood patch repair failed in both cases, but both were successfully treated with the minimally invasive application of a hydrogel dural sealant as a novel adjunct to traditional dural repair techniques. Both patients tolerated the procedure well. Moreover, SIH symptoms and MRI signs were completely resolved at 1-month follow-up in both patients. The minimally invasive dural repair procedure with hydrogel dural sealant described here offers a viable alternative in patients in whom epidural blood patches have failed, with obscure recalcitrant CSF leaks at the cervical as well as lumbar spinal level. The authors demonstrate that the adjuvant use of sealant is a safe and efficient repair method regardless of dural defect location.

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How I do it: the trans-laminar, facet-joint sparing minimal invasive approach for ventral dural repair in spontaneous intracranial hypotension—a 2-dimensional operative video

Acta Neurochirurgica ◽

10.1007/s00701-021-04987-w ◽

2021 ◽

Author(s):

Marco V. Corniola ◽

Torstein R. Meling

Keyword(s):

Minimally Invasive ◽

Intracranial Hypotension ◽

Facet Joint ◽

Spontaneous Intracranial Hypotension ◽

Skin Incision ◽

Lateral Approach ◽

Dural Defect ◽

Dural Repair ◽

Invasive Approach ◽

Minimal Invasive Approach

Abstract Background We describe the minimally invasive, facet-sparing postero-lateral approach to the thoracic spine for a ventral dural repair in a patient with intracranial hypotension secondary to a spontaneous dural breach. Methods We performed a minimally invasive approach using a short paramedian posterior skin incision followed by a 10 × 10 mm targeted trans-laminar approach, to achieve a microsurgical repair of a symptomatic ventral dural defect causing severe disability. Conclusion The facet-sparing postero-lateral approach is safe and effective in the surgical management of thoracic dural tears, even in the most anterior ones, and avoids the traditional costotransversectomy.

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Intracranial Hypotension for Anesthesiologists: What We Should Know

Pain Management Case Reports ◽

10.36076/pmcr.2019/3/69 ◽

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

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

Case Reports in Medicine ◽

10.1155/2016/9809017 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5 ◽

Cited By ~ 2

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.

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Spontaneous intracranial hypotension associated with transdural thoracic osteophyte reversed by primary dural repair

Journal of Neurosurgery Spine ◽

10.3171/spi.2005.2.5.0614 ◽

2005 ◽

Vol 2 (5) ◽

pp. 614-618 ◽

Cited By ~ 31

Author(s):

Devin K. Binder ◽

Vahé Sarkissian ◽

William P. Dillon ◽

Philip R. Weinstein

Keyword(s):

Intracranial Hypotension ◽

Surgical Intervention ◽

Median Sternotomy ◽

Spontaneous Intracranial Hypotension ◽

Imaging Features ◽

Dural Repair ◽

Content Type ◽

Csf Leakage ◽

Upper Thoracic ◽

Csf Leaks

✓ Spontaneous intracranial hypotension (SIH) is an increasingly recognized syndrome associated with a specific set of clinical and imaging findings; however, determining the site of spinal cerebrospinal fluid (CSF) leakage in these patients is often difficult, and indications for surgical intervention need to be better defined. The authors report on a 55-year-old woman who presented with posture-related headache, disorientation, and memory impairment. Imaging features were consistent with SIH. Computerized tomography myelography demonstrated a large T2–3 anterior transdural osteophyte associated with a CSF fistula. After an unsuccessful trial of conservative therapy, the patient underwent median sternotomy, T2–3 discectomy and removal of osteophyte, which allowed adequate exposure for primary dural repair. Postoperatively, there was immediate and prolonged resolution of all of her symptoms. This case of SIH was caused by transdural penetration by an anterior osteophyte and CSF leakage in the upper thoracic spine, which was treated effectively by anterior exposure and primary dural repair. Aggressive surgical intervention may be required to treat upper thoracic CSF leaks refractory to other measures.

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

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1606312 ◽

2017 ◽

Vol 79 (03) ◽

pp. 217-223 ◽

Cited By ~ 6

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.

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Use of confirmatory imaging studies to illustrate adequate treatment of cerebrospinal fluid leak in spontaneous intracranial hypotension

Journal of Neurosurgery ◽

10.3171/2010.5.jns091405 ◽

2010 ◽

Vol 113 (5) ◽

pp. 955-960 ◽

Cited By ~ 7

Author(s):

Timothy W. Vogel ◽

Brian J. Dlouhy ◽

Matthew A. Howard

Keyword(s):

Intracranial Hypotension ◽

Epidural Blood Patch ◽

Spontaneous Intracranial Hypotension ◽

Cerebrospinal Fluid Leak ◽

Neurosurgical Procedures ◽

Adequate Treatment ◽

Blood Patch ◽

Patients At Risk ◽

Fluid Leak ◽

Csf Leaks

Spontaneous intracranial hypotension (SIH) is a syndrome with serious neurological sequelae. As demonstrated by the following report, recurrent episodes of SIH can be difficult to diagnose when associated with other neurosurgical procedures, such as craniectomies. In this paper, the authors demonstrate SIH presenting as a subdural hematoma with recurrence of CSF leaks. Spontaneous intracranial hypotension was further complicated by paradoxical herniation following a craniectomy. Treatment of SIH necessitated multiple epidural blood patches for CSF leaks at different spinal levels and at different times. The efficacy of each epidural blood patch was confirmed with radionuclide imaging. Confirmation of effective blood patch placement may be useful for identifying patients at risk for a failed epidural blood patch or for patients whose neurological examination results have not fully improved.

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Minimally invasive surgery for spinal CSF-leaks in spontaneous intracranial hypotension

Brain and Spine ◽

10.1016/j.bas.2021.100761 ◽

2021 ◽

Vol 1 ◽

pp. 100761

Author(s):

J. Beck ◽

U. Hubbe ◽

J.-H. Klingler ◽

R. Rölz ◽

L.M. Kraus ◽

...

Keyword(s):

Minimally Invasive Surgery ◽

Minimally Invasive ◽

Invasive Surgery ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Csf Leaks

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

10.5327/1516-3180.641 ◽

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.

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Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20487 ◽

2020 ◽

pp. 1-9

Author(s):

Ako Matsuhashi ◽

Keisuke Takai ◽

Makoto Taniguchi

Keyword(s):

Dura Mater ◽

Fat Grafting ◽

Thoracolumbar Junction ◽

Microsurgical Anatomy ◽

Dural Defect ◽

Ct Myelography ◽

Blood Patch ◽

Neurosurgical Treatment ◽

Dural Defects ◽

Csf Leaks

OBJECTIVESpontaneous spinal CSF leaks are caused by abnormalities of the spinal dura mater. Although most cases are treated conservatively or with an epidural blood patch, some intractable cases require neurosurgical treatment. However, previous reports are limited to a small number of cases. Preoperative detection and localization of spinal dural defects are difficult, and surgical repair of these defects is technically challenging. The authors present the anatomical characteristics of dural defects and surgical techniques in treating spontaneous CSF leaks.METHODSAmong the consecutive patients who were diagnosed with spontaneous CSF leaks at the authors’ institution between 2010 and 2020, those who required neurosurgical treatment were included in the study. All patients’ clinical information, radiological studies, surgical notes, and outcomes were reviewed retrospectively. Outcomes of two different procedures in repairing dural defects were compared.RESULTSAmong 77 patients diagnosed with spontaneous CSF leaks, 21 patients (15 men; mean age 57 years) underwent neurosurgery. Dural defects were detected by FIESTA MRI in 7 patients, by CT myelography in 12, by digital subtraction myelography in 1, and by dynamic CT myelography in 1. The spinal levels of the defects were localized at the cervicothoracic junction in 16 patients (76%) and thoracolumbar junction in 4 (19%). Intraoperative findings revealed that the dural defects were small, circumscribed longitudinal slits located at the ventral aspect of the dura mater. The median dural defect size was 5 × 2 mm. The presence of dural defects at the thoracolumbar junction was associated with manifestation of an altered mental status, which was an unusual manifestation of CSF leaks (p = 0.003). Eight patients were treated via the posterior transdural approach with watertight primary sutures of the ventral defects, and 13 were treated with muscle or fat grafting. Regardless of the two different procedures, postoperative MRI showed either complete disappearance or significant reduction of the extradural CSF collection. No patient experienced postoperative neurological deficits. Clinical symptoms improved or stabilized in 20 patients with a median follow-up of 12 months.CONCLUSIONSDural defects in spontaneous CSF leaks were small, circumscribed longitudinal slits located ventral to the spinal cord at either the cervicothoracic or thoracolumbar junction. Muscle/fat grafting may be an alternative treatment to watertight primary sutures of ventral dural defects with a good outcome.

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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 ◽

10.1186/s12883-021-02279-5 ◽

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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