Radiologic Assessment of Spinal CSF Leakage in Spontaneous Intracranial Hypotension

✓ 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.

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Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

Journal of Neurosurgery ◽

10.3171/2011.12.jns111474 ◽

2012 ◽

Vol 116 (4) ◽

pp. 749-754 ◽

Cited By ~ 32

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.

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Diagnostic and surgical strategies for intractable spontaneous intracranial hypotension

Journal of Neurosurgery ◽

10.3171/jns.2001.94.4.0642 ◽

2001 ◽

Vol 94 (4) ◽

pp. 642-645 ◽

Cited By ~ 23

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.

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Three sites of high-flow CSF leakage in spontaneous intracranial hypotension

Neurology ◽

10.1212/01.wnl.0000201268.85493.af ◽

2006 ◽

Vol 66 (5) ◽

pp. 775-776 ◽

Cited By ~ 2

Author(s):

K. Hufner ◽

W. Koch ◽

M. Stander ◽

J. -C. Tonn ◽

K. Tatsch ◽

...

Keyword(s):

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

High Flow ◽

Csf Leakage

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Spontaneous Intracranial Hypotension Manifesting as a Unilateral Subdural Hematoma with a Marked Midline Shift

Case Reports in Neurology ◽

10.1159/000381667 ◽

2015 ◽

Vol 7 (1) ◽

pp. 71-77 ◽

Cited By ~ 7

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.

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An Epidurogram is an Alternative Diagnostic Tool for Discovering the Site of CSF Leakage in Spontaneous Intracranial Hypotension

Korean Journal of Anesthesiology ◽

10.4097/kjae.2001.41.1.114 ◽

2001 ◽

Vol 41 (1) ◽

pp. 114

Author(s):

Sun Ok Song ◽

Sae Yeun Kim ◽

Young Woo Cho ◽

Gi Seung Jung ◽

Yeung Ho Suh ◽

...

Keyword(s):

Diagnostic Tool ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Csf Leakage

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Severe acute orthostatic headache: spontaneous intracranial hypotension (SIH)

BMJ Case Reports ◽

10.1136/bcr-2021-243179 ◽

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.

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Spontaneous Intracranial Hypotension and MRI

Rivista di Neuroradiologia ◽

10.1177/197140099801100209 ◽

1998 ◽

Vol 11 (2) ◽

pp. 203-206

Author(s):

I. Muras ◽

A. Scuotto ◽

M. Maisto ◽

F.P. Bernini

Keyword(s):

Intracranial Hypotension ◽

Medical Condition ◽

Spontaneous Intracranial Hypotension ◽

Bed Rest ◽

Csf Leak ◽

Meningeal Enhancement ◽

Csf Leakage ◽

Downward Displacement ◽

Fluid Collections ◽

The Brain

Postural headache due to low intracranial pressure is a well-known entity and is most commonly encountered following lumbar puncture. It may occur as a consequence of a medical condition (dehydratation, uremia, etc.) but in some cases no precipitating event is apparent and the intracranial hypotension is believed to have developed spontaneously. In such cases the underlying cause of the syndrome is rarely established and treatment is non specific. We describe three patients with spontaneous intracranial hypotension examined with MRI of the brain. Women are more commonly affected than men in the third or fourth decades of life. Schaltenbrand (1938) proposed three mechanisms by which spontaneous intracranial hypotension may be explained: diminished CSF production; CSF hyperabsorption, CSF leakage. The defect causing a CSF leak usually remains obscure. Several cases of diffuse meningeal enhancement on MRI have recently been described, probably due to meningeal hyperaemia resulting from the low CSF pressure. Subdural fluid collections have also been detected as a result of rupture of bridging veins due to the decrease in CSF volume and downward displacement of the brain. In our cases, MRI showed a diffuse dural thickening, hyperintense in T2. Spontaneous intracranial hypotension is often a self-limiting disease, responding well to bed rest and a generous intake of oral or parenteral fluid and salt.

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10-Year follow-up of csf leakage by serial neuroimages in a patient with protracted spontaneous intracranial hypotension

Journal of the Neurological Sciences ◽

10.1016/j.jns.2017.08.509 ◽

2017 ◽

Vol 381 ◽

pp. 175-176

Author(s):

Y.C. Chu ◽

J.L. Fuh ◽

Y.F. Wang ◽

C. Shih-Pin ◽

L. Jiing-Feng ◽

...

Keyword(s):

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Csf Leakage

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Minimally invasive repair of spontaneous intracranial hypotension

Journal of Neurosurgery ◽

10.3171/2010.8.jns10412 ◽

2011 ◽

Vol 114 (2) ◽

pp. 505-509 ◽

Cited By ~ 2

Author(s):

Hamad I. Farhat ◽

Brian Hood ◽

Steven Vanni ◽

Allan D. Levi

Keyword(s):

Minimally Invasive ◽

Intracranial Hypotension ◽

Therapeutic Option ◽

Treatment Options ◽

Spontaneous Intracranial Hypotension ◽

Surgical Correction ◽

Invasive Approach ◽

Epidural Blood Patching ◽

Csf Leakage ◽

Cerebrospinal Fluid Leaks

Spontaneous spinal CSF leakage with the development of intracranial hypotension is a well-described entity. Cerebrospinal fluid leaks, mostly from the thoracic spine, are the major cause of spontaneous intracranial hypotension (SIH). Conservative treatment options include hydration, oral caffeine, and epidural blood patching. Alternatively, open surgical correction of meningeal diverticula is a therapeutic option. The authors describe 4 cases of spontaneous spinal CSF leakage producing symptoms of intracranial hypotension. All patients had multiple spinal diverticula with an identified leaking level. The patients were treated using a minimally invasive approach via surgical correction of the meningeal diverticulum.

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