Successful management of spontaneous intracranial hypotension with epidural blood patch

Spontaneous intracranial hypotension (SIH) is characterised by postural headache and a cerebrospinal fluid (CSF) pressure of ≤6 cmH20 measured with the patient in the lateral decubitus position. Other symptoms include tinnitus, altered hearing, diplopia, photophobia, nausea and neck stiffness, and must not have occurred within a month of dural puncture. Symptoms typically remit after normalisation of CSF pressure or successful sealing of the CSF leak. An epidural blood patch (EBP) is a treatment option in those who have not responded to bed rest, fluids, non-steroidal anti-inflammatories or caffeine. We present a case of SIH successfully treated with both conservative measures and EBP. We compare our case with similar cases in the literature and summarise what is known about EBP for SIH to help clinicians take a more informed approach to managing such patients.

Fascia lata packing and tension suturing for symptomatic pseudomeningocele after recurrent cervical intradural tumour resection

In recurrent posterior cervical intradural tumour resections, serious complications can be developed. The dural can become affected by inflammatory factors or removed during tumor resection; if cerebrospinal fluid (CSF) leakage cannot be stopped by duraplasty, artificial meninges or fascia repair, large pseudomeningocele can develop posteriorly within the soft tissue of the neck. When the pressure of the CSF cannot be maintained steadily, persistent clinical symptoms can occur, such as postural headache or central fever. Moreover, the skin can also be penetrated in a few patients even after extension of the drainage duration, lumbar cistern drainage or skin suturing, leading to the induction of life-threatening intra-cranial infections. Is there a simple and effective surgical method to address this scenario? The aim of this study was, therefore, to investigate the effectiveness of fascia lata packing and tension suturing in the treatment of symptomatic pseudomeningocele after recurrent posterior cervical intradural tumour resection. In our study, nine consecutive spinal surgery patients were recruited from January 2008 to January 2018. All pseudomeningoceles were combined with postural headache, central neurological fever or wound non-union. There were 3 cases of melanocytoma, 3 cases of nasopharyngeal carcinoma metastasis, 2 cases of breast cancer metastasis, and 1 case of spinal canal lymphadenoma. Standard patient demographics, diagnosis, post-operative symptoms, wound healing time, and the largest pre- and last follow-up pseudomeningocele area on axial MRI sections were recorded. All cases were followed-up successfully, from 12 to 24 months, with an average of 15.3 months. Our observations indicate that all wounds healed successfully. The wound union time was 20.7 days on average. After wound union, these patients became symptom free. The largest cerebrospinal fluid area on axial MRI sections improved significantly from 42.9 ± 5.01 cm2 at p re-operation to 6.6 ± 1.89 cm2 at 1 year post-operation (P < 0.05); Our data indicate that .the proposed procedure is simple, safe and effective. And more importantly, it allows rapid closure of any cerebrospinal fluid leakage pools.

Intracranial Hypotension After Severe Covid-19. Case Report and Literature Review.

Background: Despite the lack of clinical research done, new mutations of COVID-19 are travelling all over the world, and sooner or later, unexpected consequences going to be seen. In October 2020 new variant of SARV-CoV-2 (known as 20H/501.V2 or B1.351) has been found in our province (Eastern Cape), South Africa. This variant has multiple mutations in the spike protein, including K417N, E484K, N501Y. We did an extensive review of the medical literature (It is not a systematic review), looking for all publications regarding spontaneous intracranial hypotension, subdural effusions SARS-CoV-2/COVID-19. Case Presentation: We also report a case of 46-years-old-female admitted severe COVID-19 in the intensive care unit; all performed investigations confirmed the severity of the infection caused by SARS-CoV-2. Past medical history proved a chronic headache, standard routine CSF analysis, and normal MRI of the brain three months before admission.The patient recovered from the respiratory pathology and went home, but two weeks later, she developed a postural headache. We suspect spontaneous intracranial hypotension, and the CSF pressure (5.5 cm of H2O) confirmed it. CT scan of the head showed bilateral frontal subdural effusion. Conclusion: We did not find any published report related to COVID-19, subdural effusion, and intracranial hypotension. We elaborated a few comments and hypotheses to explain this process’s probable pathophysiology.

An unusual postural headache: a case report

Background This paper presents a case of an evolving unusual thunderclap headache that presented to a chiropractor. Case presentation The intense “migraine-like” headache was aggravated by standing up and relieved substantially when lying down. This low pressure, orthostatic headache was diagnosed as a spontaneous intracranial hypotension (SIH) secondary to a spontaneous tear of the dura. It was referred to the local hospital for management with autogolous blood injection to form an epidural blood patch of the defect. It resolved substantially within 3 days. Conclusions The significance of key features in the history and examination and how if not recognised and subsequently treated with manual therapy, the dural tear could be attributed to the treatment of the chiropractor, a treatment that would typically involve cervical manipulation. Discussion is provided of the implications of a missed diagnosis and possible subsequent chiropractic management with the evolving SIH being attributed to the chiropractic intervention rather than its true “spontaneous” nature.

Parinaud syndrome as an unusual presentation of intracranial hypotension

Background: Vertical gaze palsy is a rare clinical manifestation of intracranial hypotension. The typical features of intracranial hypotension include a postural headache, dural enhancement, and low cerebrospinal fluid (CSF) opening pressure. Case Description: We describe a case of a shunt-dependent middle-aged female with aqueductal stenosis who developed recurrent presentations of upgaze palsy with postural headaches, confirmed low opening pressure, and slit ventricles on magnetic resonance imaging (MRI) due to shunt overdrainage. Her ophthalmoplegia and headaches improved following third ventriculostomy and with increasing the shunt opening pressure to prevent excess CSF drainage. Conclusion: Intracranial hypotension should be considered part of the differential diagnosis for patients presenting with an upgaze palsy.

Clinical performance of fixed-pressure Sphera Duo® hydrocephalus shunt

Introduction: Cerebral hydrodynamics complications in shunted patients are due to the malfunction of the system. The objective of this retrospective, single-center, single-arm cohort study is to confirm the safety and performance of Sphera® Duo when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cysts. Methods: Data were generated by reviewing 112 adult patient’s charts, who were submitted to a ventriculoperitoneal shunt surgery and followed for one year after surgery. Results: The results show us that 76% of patients had their neurological symptoms improved and that the reoperation rate was 15% in the first year following surgery. Discussion: Sphera Duo® shunt system is an applicable shunt option in routine neurosurgical management of hydrocephalus by several causes. It has presented good results while mitigating effects of overdrainage. Overdrainage is especially important in adults with non-hypertensive hydrocephalus and can cause functional shunt failure, which causes subnormal ICP (particularly in the upright position) and is associated with characteristic neurological symptoms, such as postural headache and nausea. Conclusion: Sphera Duo® shunt system is safe when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cyst.

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

BackgroundThis double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial.MethodsOne hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed.A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0–10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache.ResultsOut of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: −3.2 to −0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache.ConclusionDural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies.Trial registration numberNCT03389945.

Vertebral artery dissection stroke in evolution presented with postural headache as initial manifestation

In young adult, the most common etiology of acute ischemic brain infarction are arterial dissections and cardiogenic embolic stroke. Vertebral artery dissection without preceding trauma history is quite rare in young ischemic stroke patients. Postural headache is even more atypical presentation for vertebral artery dissection. It is often misdiagnosed as spontaneous intracranial hypotension. We described a 37-year-old male suffering from acute onset postural headache with stroke in evolution during hospitalization. The initial brain magnetic resonance imaging (MRI) mislead to diagnosis of ischemic lesion. Nevertheless, with the aid of single photon emission computed tomography, we are confident the patient was afflicted with ischemic/hemorrhagic lesion, instead of neoplasm or demyelinating diseases. Lateral medullary syndrome was confirmed on the repeated brain MRI. His general condition improved with steady gait and clear articulation without easychoking after adequate hydration and rehabilitation training with aspirin as secondary prevention. Cranial artery dissections is a crucial differential diagnosis while thunderclap headache happens even related to postural change without obvious neurological deficit in the beginning presentations.