Algorithmic Multimodality Approach to Diagnosis and Treatment of Spinal CSF Leak and Venous Fistula in Patients With Spontaneous Intracranial Hypotension

Callen, Andrew L.; Timpone, Vincent M.; Schwertner, Adam; Zander, David; Grassia, Fabio; Lennarson, Peter J.; Seinfeld, Joshua; Lillehei, Kevin O.; Birlea, Marius; Thaker, Ashesh A.

doi:10.2214/ajr.22.27485

Cited by 29 publications

(24 citation statements)

References 24 publications

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“…10,13 Both dCTM and DSM are used at quaternary SIH referral centers, and each modality has specific strengths and weaknesses, which have been previously described. 22 Our data support the growing use of dCTM as an alternative to DSM in patients with brain changes associated with an elevated Bern score.…”

Section: Discussionsupporting

confidence: 80%

“…(Figure 1) "Pressure-augmentation" refers to the infusion of incremental aliquots of sterile saline through a spinal needle. 22 Imaging reports of dCTM studies were collected using a report search engine tool through the electronic medical record (Primordial Prism) which identified all reports associated with dCTM procedures in the specified time period. When pressure-augmentation was performed, the OP, volumes of saline infusion, and incremental pressure measurements were recorded in a standardized format in the body of the procedural report by the proceduralist.…”

Section: Data Acquisition and Patient Selectionmentioning

confidence: 99%

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Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

et al. 2023

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Background and Objectives:Existing tools to diagnose spontaneous intracranial hypotension (SIH), namely spinal opening pressure (OP) and brain MRI, have limited sensitivity. We investigated whether evaluation of brain MRI using the Bern Score, combined with calculated craniospinal elastance, would aid in diagnosing SIH and provide insight into its pathophysiology.Methods:A retrospective chart review was performed of patients who underwent brain MRI and pressure-augmented dynamic CT myelography (dCTM) for suspicion of SIH. Two blinded Neuroradiologists assigned Bern Scores for each brain MRI. OP and incremental pressure changes after intrathecal saline infusion were recorded to calculate craniospinal elastance. The relationship between Bern Score, OP, elastance, and whether a leak was found were analyzed.Results:72 consecutive dCTMs were performed in 53 patients. 12 CSF-venous fistulae, two ruptured meningeal diverticula, two dural defects, and one dural bleb were found (17/53=32%). Among patients with imaging proven CSF leak/fistula, OP was normal in all but one patient, and was not significantly different in those with a leak compared to those without (15.1 vs 13.6 cm H2O, p = 0.24, A=0.40). Average Bern Score in individuals with a leak was significantly higher than in those without (5.35 vs 1.85, p < 0.001, A=0.85), even when excluding pachymeningeal enhancement from the score (3.77 vs 1.57, p = 0.001, A=0.78). Average elastance in those with a leak was higher than in those without, but this difference was not statistically significant (2.05 vs 1.20 mL/cm H2O, p = 0.19, A=0.40). Increased elastance was significantly associated with an increased Bern Score (p < 0.01, 95% CI -0.55, 0.12), and was significantly associated with venous distention, pachymeningeal enhancement, prepontine narrowing, and subdural collections, but not a narrowed mamillopontine or suprasellar distance.Discussion:OP is not an effective predictor for diagnosing CSF leak, and if used in isolation would result in misdiagnosis of 94% of patients in our cohort. The Bern Score was associated with a higher diagnostic yield of dCTM. Elastance was significantly associated with certain components of the Bern Score.

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Section: Discussionsupporting

confidence: 80%

Section: Data Acquisition and Patient Selectionmentioning

confidence: 99%

Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

et al. 2023

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“…To our knowledge a multidisciplinary consensus-based guideline for SIH has not previously been produced. Previously published algorithms for management of SIH are from single centres which may be biased by local factors, or do not cover the whole patient pathway 13–16. We have also included aspects of SIH which were identified as especially important to patients including differential diagnosis, identification of comorbidities and symptom management.…”

Section: Discussionmentioning

confidence: 99%

Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension

Cheema

Anderson

Angus‐Leppan

et al. 2023

J Neurol Neurosurg Psychiatry

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BackgroundWe aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG).MethodsA 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH.ResultsSIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided.ConclusionsThis multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.

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“…Generally, surgical repair is considered if other minimally invasive techniques have failed. Those interventional techniques include targeted epidural blood patch (EBP) or fibrin glue injection,3–5 and the recently reported transvenous embolization technique for CSF-venous fistulas (CVF) 6 7. However, the efficacy of percutaneous techniques can vary substantially 3.…”

Section: Introductionmentioning

confidence: 99%

CT-guided percutaneous cyanoacrylate injection targeting the spinal cerebrospinal fluid leak: a potential therapeutic option for spontaneous intracranial hypotension

Liao¹,

Tonnelet

Schmitt³

et al. 2023

J NeuroIntervent Surg

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BackgroundWe report the first case series of spontaneous intracranial hypotension (SIH) patients who underwent CT-guided percutaneous cyanoacrylate injection targeting the cerebrospinal fluid (CSF) leak.MethodsA retrospective analysis was performed for all consecutive cases of SIH patients with CSF leak confirmed on CT myelography, treated by CT-guided percutaneous cyanoacrylate injection at our institution from 2016 to 2022. On pretreatment brain and spine MRIs, we analyzed signs of SIH according to the Bern score, and dichotomized cases into positive/negative for spinal longitudinal extradural CSF collection (SLEC-P or SLEC-N). The leaks detected on CT myelography were classified into three types according to Schievinket al. We collected the Headache Impact Test 6 (HIT-6) scores throughout a 6-month follow-up, with a brain CT scan at each visit.Results11 patients were included (mean age 48.4 years, six men). Five SLEC-P type 1, three SLEC-P type 2, and three SLEC-N type 3 leaks were identified. All patients had significant signs of SIH on pretreatment brain MRI (mean Bern score 7.8±1.1). Six patients underwent a foraminal puncture, and five patients had a cervical epidural approach. Two patients experienced mild and transient locoregional pain after cervical epidural injection. Mean HIT-6 score at baseline was 66.8±3.2 and at the 6-month follow-up was 38±3.6 (P<0.001). All patients achieved improvement in their symptoms, with 82% of them (9/11) having complete resolution of headaches and SIH findings on CT scans at 6 months. No clinical worsening or recurrence was observed.ConclusionsCT-guided percutaneous cyanoacrylate injection may be a potential therapeutic option for the different types of CSF leak causing SIH.

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Algorithmic Multimodality Approach to Diagnosis and Treatment of Spinal CSF Leak and Venous Fistula in Patients With Spontaneous Intracranial Hypotension

Cited by 29 publications

References 24 publications

Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension

Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension

CT-guided percutaneous cyanoacrylate injection targeting the spinal cerebrospinal fluid leak: a potential therapeutic option for spontaneous intracranial hypotension

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