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

2005 ◽  
Vol 2 (5) ◽  
pp. 614-618 ◽  
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.

Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography

2000 ◽  
Vol 92 (5) ◽  
pp. 873-876 ◽  
Author(s):  
Akira Matsumura ◽  
Izumi Anno ◽  
Hiroshi Kimura ◽  
Eiichi Ishikawa ◽  
Tadao Nose
Keyword(s):  
Magnetic Resonance ◽  
Intracranial Hypotension ◽  
Direct Evidence ◽  
Spontaneous Intracranial Hypotension ◽  
Content Type ◽  
Highly Sensitive ◽  
Csf Leakage ◽  
Leakage Site ◽  
A Site ◽  
Mr Myelography

✓ The authors describe a case of spontaneous intracranial hypotension in which the leakage site was determined by using magnetic resonance (MR) myelography. This technique demonstrated the route of cerebrospinal fluid (CSF) leakage, whereas other methods failed to show direct evidence of leakage. Magnetic resonance myelography is a noninvasive method that is highly sensitive in detecting CSF leakage. This is the first report in which a site of CSF leakage was detected using MR myelography.

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.

Diagnostic and surgical strategies for intractable spontaneous intracranial hypotension

2001 ◽  
Vol 94 (4) ◽  
pp. 642-645 ◽  
Author(s):  
Chikanori Inenaga ◽  
Tokutaro Tanaka ◽  
Naoki Sakai ◽  
Shigeru Nishizawa
Keyword(s):  
Computerized Tomography ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Upright Position ◽  
Breath Holding ◽  
Content Type ◽  
Radionuclide Cisternography ◽  
Csf Leakage ◽  
Upper Cervical ◽  
Fine Print

✓ The authors present the case of a 55-year-old man suffering from intractable spontaneous intracranial hypotension, in whom conservative treatment with 19 weeks of bed rest was not effective. In this period the patient twice underwent surgery for bilateral chronic subdural hematoma, a complication of spontaneous intracranial hypotension. Conventional radionuclide cisternography, magnetic resonance imaging, and computerized tomography myelography did not demonstrate cerebrospinal fluid (CSF) leakage. Repeated radionuclide cisternography with the patient in an upright position revealed leakage of the tracer at upper cervical levels. Computerized tomography myelography with breath holding also showed CSF leakage of the contrast medium bilaterally at upper cervical levels. The patient underwent surgery, and bilateral C-2 and C-3 spinal nerve root pouches were sealed off from the subarachnoid space with oxidized cellulose cotton and fibrin glue. Epiarachnoid spaces around the root sleeves were also sealed to ensure complete resolution of the CSF leakage. After the surgery, the patient was completely free of the disease. In the case of intractable persistent spontaneous intracranial hypotension, surgical treatment is preferable to long-term conservative management. To identify CSF leakage, radionuclide cisternography with the patient in the upright position is useful. When obvious leakage is encountered, surgical sealing of the lesion should be performed via a subarachnoid approach.

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

2014 ◽  
Vol 121 (4) ◽  
pp. 976-982 ◽  
Author(s):  
Casey M. Chai ◽  
Matei A. Banu ◽  
William Cobb ◽  
Neel Mehta ◽  
Linda Heier ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Intracranial Hypotension ◽  
Fluid Collection ◽  
Spontaneous Intracranial Hypotension ◽  
Patch Repair ◽  
Surgical Approaches ◽  
Dural Defect ◽  
Dural Repair ◽  
Blood Patch ◽  
Csf Leaks

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.

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 spinal cerebrospinal fluid leaks and intracranial hypotension

1996 ◽  
Vol 84 (4) ◽  
pp. 598-605 ◽  
Author(s):  
Wouter I. Schievink ◽  
Fredric B. Meyer ◽  
John L. D. Atkinson ◽  
Bahram Mokri
Keyword(s):  
Cerebrospinal Fluid ◽  
Thoracic Spine ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Cervicothoracic Junction ◽  
Ct Myelography ◽  
Content Type ◽  
Fine Print ◽  
Csf Leaks

✓ Spinal cerebrospinal fluid (CSF) leaks are often implicated as the cause of the syndrome of spontaneous intracranial hypotension, but they have rarely been demonstrated radiographically or surgically. The authors reviewed their experience with documented cases of spinal CSF leaks of spontaneous onset in 11 patients including their surgical observations in four of the patients. The mean age of the six women and five men included in the study was 38 years (range 22–51 years). All patients presented with a postural headache; however, most had additional symptoms, including nausea, emesis, sixth cranial-nerve paresis, or local back pain at the level of the CSF leak. All patients underwent indium-111 radionucleotide cisternography or computerized tomographic (CT) myelography. The location of the spontaneous CSF leak was in the cervical spine in two patients, the cervicothoracic junction in three patients, the thoracic spine in five patients, and the lumbar spine in one patient. The false negative rate for radionucleotide cisternography was high (30%). Subdural fluid collections, meningeal enhancement, and downward displacement of the cerebellum, resembling a Chiari I malformation, were commonly found on cranial imaging studies. In most patients, the symptoms resolved in response to supportive measures or an epidural blood patch. Leaking meningeal diverticula were found to be the cause of the CSF leak in four patients who underwent surgery. In three patients these diverticula could be ligated with good result but in one patient an extensive complex of meningeal diverticula was found to be inoperable. Two patients had an unusual body habitus and joint hypermobility, and two other patients had suffered a spontaneous retinal detachment at a young age. In conclusion, spontaneous spinal CSF leaks are uncommon, but they are increasingly recognized as a cause of spontaneous intracranial hypotension. Most spinal CSF leaks are located at the cervicothoracic junction or in the thoracic spine, and they may be associated with meningeal diverticula. The radiographic study of choice is CT myelography. The disease is usually self-limiting, but in selected cases our experience with surgical ligation of leaking meningeal diverticula has been satisfactory. An underlying connective tissue disorder may be present in some patients with a spontaneous spinal CSF leak.

scholarly journals Surgical intervention for spontaneous intracranial hypotension Type 4 CSF leak: A case report

2020 ◽  
Vol 11 ◽  
pp. 421
Author(s):  
Saba Shahab ◽  
Mohamed A. R. Soliman ◽  
Abdullah F. Alkhamees ◽  
Sydney Eaton ◽  
Elise Quint ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Conservative Therapy ◽  
Surgical Intervention ◽  
Spontaneous Intracranial Hypotension ◽  
Rare Condition ◽  
Csf Leak ◽  
Mri Scans ◽  
The Brain ◽  
Csf Leaks

Background: Spontaneous intracranial hypotension (SIH) is a rare condition that can be very debilitating. SIH is well understood to be due to a CSF leak, however, identifying the source of the leak is still a challenge. We are presenting a case of Type 4 CSF leak and reviewing the related literature. Case Description: A 46-year-old female presenting with intractable orthostatic headaches was diagnosed with SIH. She was unable to mobilize due to the severity of her symptoms. MRI scans of the brain and spine did not identify a source of the leak. After failing conservative therapy and multiple epidural blood patches, the patient underwent surgery which resulted in significant improvement in symptoms. Conclusion: This study has shown that surgical intervention improves symptoms in patients who do not have an identifiable source of CSF leak. Further studies need to be done to fully understand the role of surgery in Type 4 CSF leaks.

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

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.

Treatment of spontaneous intracranial hypotension with percutaneous placement of a fibrin sealant

2004 ◽  
Vol 100 (6) ◽  
pp. 1098-1100 ◽  
Author(s):  
Wouter I. Schievink ◽  
M. Marcel Maya ◽  
Franklin M. Moser
Keyword(s):  
Fibrin Sealant ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Invasive Treatment ◽  
Content Type ◽  
Epidural Blood Patching ◽  
Lower Thoracic Spine ◽  
Fine Print ◽  
Csf Leaks

✓ Spontaneous intracranial hypotension due to a cerebrospinal fluid (CSF) leak in the spine is an important cause of new, daily persistent headaches. Most patients respond well to conservative treatments including epidural blood patching. Limited options for effective treatment are available for patients in whom these treatments fail. The authors treated four patients (mean age 38 years; range 26–43 years) with percutaneous placement of a fibrin sealant. All these patients presented with intractable positional headaches. The CSF leak was located in the lower cervical spine in three patients and in the lower thoracic spine in one patient. Four to 20 milliliters of fibrin sealant was injected at the site of the CSF leak. Two of the four patients became asymptomatic within days of the procedure and thus avoided surgery. There were no complications of this procedure. Percutaneous placement of a fibrin sealant is a safe, minimally invasive treatment for spontaneous spinal CSF leaks and should be considered in patients in whom conservative treatment has failed.

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 

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