Intracranial Hypotension for Anesthesiologists: What We Should Know

Case Series ◽

Low Flow ◽

Csf Leak ◽

Common Denominator ◽

Invasive Treatment ◽

Blood Patch ◽

Mechanism Of Trauma ◽

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

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):

Epidural Blood Patch ◽

Complete Recovery ◽

Csf Leak ◽

Ct Guided ◽

Blood Patch ◽

History Of ◽

Persistent Headache ◽

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.

Intradural extraarachnoid sutureless technique combined with laminoplasty for indirect repair of ventral dural defects in spontaneous intracranial hypotension: technical note and case series

Acta Neurochirurgica ◽

10.1007/s00701-021-04868-2 ◽

2021 ◽

Author(s):

M. Kamenova ◽

S. Schaeren ◽

M-G. Wasner

Keyword(s):

Surgical Technique ◽

Treatment Strategies ◽

Case Series ◽

Technical Note ◽

Csf Leak ◽

Sutureless Technique ◽

Dural Defects ◽

Abstract Background There is a significant variance in surgical treatment strategies of ventral cerebrospinal fluid (CSF) leaks causing spontaneous intracranial hypotension (SIH). Posterior approaches might represent a preferable alternative to the more invasive anterior and lateral routes, as long as the spinal cord is not exposed to harmful manipulation. The aim of this technical note is to report and illustrate a new surgical technique using an intradural extraarachnoid sutureless technique via laminoplasty for indirect repair of ventral CSF leaks causing intractable SIH symptoms. Methods The surgical technique is described in a step by step fashion. Between May 2018 and May 2020, five patients with ventral spinal CSF leaks were operated on, utilizing this technique. All dural defects were located at the level of the thoracic spine. A retrospective review on demographic and radiological findings, symptoms, outcome, and follow-up was performed. Results The intra- and postoperative course was uneventful in all patients with no surgery-related complications. Three patients recovered completely at discharge, while neurological symptoms significantly improved in two patients. A postoperative MRI of the spine was obtained for all patients, demonstrating regressive signs of CSF leak. Conclusion Based on the presented case series, this intradural extraarachnoid sutureless technique combined with laminoplasty seems to be a safe and effective option for indirect repair of ventral dural defects in SIH. In our opinion, it represents a valid alternative to traditional more aggressive approaches.

Fast effective treatment of spontaenous CSF leak causing intracranial hypotension and debilitating orthostatic headache

MOJ Clinical & Medical Case Reports ◽

10.15406/mojcr.2020.10.00338 ◽

2020 ◽

Vol 10 (2) ◽

pp. 36-39

Author(s):

Heike Jacobs

Keyword(s):

Clinical Laboratory ◽

Case Series ◽

Abrupt Onset ◽

Acute Onset ◽

Orthostatic Headache ◽

Csf Leak ◽

Blood Patch ◽

Lumbar Area

We are reporting a case series describing clinical, laboratory, MRI and CT myelogram imaging and treatment results for 4 patients with spontaneous cerebral spinal fluid (CSF) leak with subsequent intracranial hypotension; all of which resolved via blood patches. A 33-year-old woman (case 1) presented abrupt onset severe pain in the back and head; without preceding trauma or procedure. MRI brain revealed leptomeningeal enhancement, after CT myelogram identifying a CSF leak she received a 20ml epidural blood patch in the lumbar area. By the next day her symptoms had completely resolved. A 36year old woman (case 2) with 1 year-long history of positional headaches. Her CT Myelogram showed frequent multilevel Tarlov Cysts; one of which displayed leakage. Her orthostatic headaches disappeared after repeated EBP. A middle aged male (case 3) had an acute onset headache which persisted with orthostatic features since 6 weeks. He had complete remission after one epidural patching. A 47 year old man (case 4) presented with 5 days of typical orthostatic headaches, CT Myelogramm demonstrated a leaking thoracolumbar cyst. He required 2 EBP within 3 days to completely recover. Our cases support the notion that blood patching is a fast, effective and safe treatment for an increasingly recognized diagnosis of orthostatic headache caused by spontaneous intracranial hypotension.

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

Journal of Neurosurgery ◽

10.3171/jns.2004.100.6.1098 ◽

2004 ◽

Vol 100 (6) ◽

pp. 1098-1100 ◽

Cited By ~ 58

Author(s):

Wouter I. Schievink ◽

M. Marcel Maya ◽

Franklin M. Moser

Keyword(s):

Fibrin Sealant ◽

Csf Leak ◽

Invasive Treatment ◽

Content Type ◽

Epidural Blood Patching ◽

Lower Thoracic Spine ◽

Fine Print ◽

✓ 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.

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 ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Spinal Imaging ◽

Radiological Data ◽

Single Instance ◽

Csf Leakage ◽

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.

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

Journal of Neurosurgery ◽

10.3171/2014.6.jns13714 ◽

2014 ◽

Vol 121 (4) ◽

pp. 976-982 ◽

Cited By ~ 3

Author(s):

Casey M. Chai ◽

Matei A. Banu ◽

William Cobb ◽

Neel Mehta ◽

Linda Heier ◽

...

Keyword(s):

Minimally Invasive ◽

Fluid Collection ◽

Patch Repair ◽

Surgical Approaches ◽

Dural Defect ◽

Dural Repair ◽

Blood Patch ◽

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.

Movement disorders associated with spontaneous CSF leaks: A case series

Cephalalgia ◽

10.1177/0333102414531154 ◽

2014 ◽

Vol 34 (14) ◽

pp. 1134-1141 ◽

Cited By ~ 9

Author(s):

Bahram Mokri

Keyword(s):

Movement Disorder ◽

Movement Disorders ◽

Complete Resolution ◽

Valsalva Maneuver ◽

Case Series ◽

Csf Leak ◽

Low Grade ◽

Common Symptom ◽

Blood Patch ◽

Importance and Objective Headache is the most common symptom in spontaneous CSF leaks, frequently associated with additional manifestations. Herein, attention is drawn to movement disorder as a notable manifestation of spontaneous CSF leaks. Design Four women and one man (ages 51–78 years) with spontaneous CSF leaks and movement disorders were evaluated clinically and by pertinent neuroimaging studies with follow-up of one to seven years (mean 3.2 years). Results The movement disorder consisted of choreiform movements in two patients, torticollis in one, mixed tremor in one, and parkinsonism in one. All except the last patient had headaches (orthostatic in one, Valsalva maneuver-induced in one, both orthostatic and Valsalva-induced in two, lingering low-grade headache in one). Diffuse pachymeningeal enhancement and sinking of the brain was noted in all. CT-myelography showed definite CSF leak in three and equivocal leak in one, while no leak could be located in the fifth patient. Two patients improved over time with complete resolution of the movement disorder. One responded to epidural blood patch with complete resolution of his choreiform movements. Two patients required surgery and epidural blood patches. Results were drastic but nondurable in one, while complete recovery was achieved in the other. Conclusion Movement disorders are uncommon in spontaneous CSF leaks but occasionally can be one of the major components of the clinical presentation.

Thoracic Epidural Blood Patches in the Treatment of Spontaneous Intracranial Hypotension: A Retrospective Case Series

January 2018 - Pain Physician ◽

10.36076/ppj.2015/18/343 ◽

2015 ◽

Vol 18;4 (4;18) ◽

pp. 343-348

Author(s):

Paolo Feltracco

Keyword(s):

Autologous Blood ◽

Case Series ◽

Retrospective Case ◽

Retrospective Case Series ◽

Blood Patch ◽

Epidural Puncture ◽

Headache Relief

Background: Spontaneous intracranial hypotension (SIH) results from leaks developing in the dura mater. The major symptom is orthostatic headache which gradually disappears after lying down. Lumbar epidural blood patches (EBPs) can be effective in relieving headaches, however, thoracic and cervical EBPs have also been applied to alleviate the symptoms. Objective and Methods: Retrospective collection of the main characteristics of SIH, site and amount of blood injection, and clinical outcomes of 18 patients who underwent thoracic EBPs for intractable SIH. { Study Design: Retrospective case series Results: All thoracic autologous EBPs except 3 were performed in the sitting position. Patients undergoing epidural puncture at lower thoracic levels (T10-T12) received 25 mL of autologous blood, 15 mL and 18 mL were injected at spinal segments T5-T7 (mid-thoracic) and T2-T4 (upperthoracic), respectively. Thoracic EBPs did not lead to immediate resolution of symptoms in 3 of 18 patients; one of them underwent early repetition with complete headache relief, one refused a second EBP, and one experienced partial resolution, followed by a recurrence, and then satisfactory improvement with a second high thoracic EBP. In long-term follow-up only 2 patients complained of symptoms or relapses. Limitations: Retrospective nature of the case series, single center experience. Conclusions: Performing thoracic-targeted EBPs as the preferred approach theoretically improves results with respect to those observed with lumbar EBPs. The immediate response was comparable with that of other reports, but the long-term success rate (90%) turned out to be very effective in terms of both quality of headache relief and very low incidence of recurrence. Key words: Central pain, cerebrospinal fluid leak, headache disorders, low intracranial pressure syndrome, epidural blood patch, occipital headache

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):

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.

Headache attributed to spontaneous intracranial hypotension

Oxford Textbook of Headache Syndromes ◽

10.1093/med/9780198724322.003.0038 ◽

2020 ◽

pp. 346-355

Author(s):

Farnaz Amoozegar ◽

Esma Dilli ◽

Rashmi B. Halker ◽

Amaal J. Starling

Keyword(s):

Clinical Symptoms ◽

Csf Leak ◽

Non Invasive ◽

Appropriate Treatment ◽

Clinical Presentations ◽

Blood Patch ◽

Underlying Pathophysiology ◽

Diagnostic Investigations

Spontaneous intracranial hypotension (SIH) caused by a spontaneous cerebrospinal fluid (CSF) leak, results in CSF hypovolaemia. Owing to the variety of clinical presentations and numerous possible diagnostic investigations, diagnosis and appropriate treatment remains challenging in many patients. Although the typical presentation of SIH is an orthostatic headache, the clinical spectrum includes a variety of headache types, focal neurological symptoms, and even spinal manifestations. The underlying pathophysiology of SIH varies depending on the clinical scenario. However, a deeper understanding of the pathophysiology has led to the recognition of risk factors and an explanation for clinical symptoms and abnormalities on diagnostic investigations. Multiple diagnostic investigations can be used to determine if a CSF leak is present or not. Magnetic resonance imaging of the head with and without contrast is sensitive and non-invasive. However, computed tomography myelography remains the study of choice to locate the site of the leak. The rate of flow of the CSF leak can pose a challenge to standard diagnostic investigations. To date, a large-volume blind epidural blood patch is the mainstay of treatment, although more targeted approaches are used for more refractory cases.