Spontaneous intracranial hypotension

Cho, K.-I.; Moon, Heeyoung; Jeon, Hyun Sun; Park, K.; Kong, Doo‐Sik

doi:10.1212/wnl.0b013e318212ab43

Cited by 146 publications

(117 citation statements)

References 21 publications

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“…To the best of our knowledge, the detailed analysis of CT myelography, which is less invasive and can be performed easily on a routine basis, has yet to be described in the literature. 2,8,[16][17][18] The study reported here raises the following 4 points with regard to the diagnosis and treatment of spontaneous CSF leaks. First, EBP at the level near the spinal lesions resulted in good outcomes.…”

Section: Discussionmentioning

confidence: 86%

“…2 The cure rate for targeted EBP is 70%-100% (which is higher than that for nontargeted lumbar EBP), and the amount of blood injected is smaller; however, targeted EBP requires identification of the exact leak site. Although the use of targeted EBP is increasingly being reported, previous studies have not described in detail how to determine the leak site and target the spinal level for EBP.…”

mentioning

confidence: 99%

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Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Yoshida¹,

Takai²,

Taniguchi³

2014

SPI

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Object The purpose of this study was to describe significant CT myelography findings for determination of the leak site and outcome of targeted epidural blood patch (EBP) in patients with spontaneous CSF leaks. Methods During 2005–2013, spontaneous CSF leaks were diagnosed for 12 patients with orthostatic headaches. The patients received targeted EBP on the basis of CT myelography assessments. Results Computed tomography myelograms revealed ventral extradural collection of contrast medium distributed over multiple spinal levels (average 16 levels). Intraforaminal contrast medium extravasations were observed at multiple spinal levels (average 8.2 levels). For 8 (67%) of 12 patients, spinal lesions were noted around the thecal sac and included calcified discs with osteophytes, an ossified posterior longitudinal ligament, and an ossified yellow ligament; lesions were mostly located ventral to the thecal sac and were in close contact with the dura mater. The levels of these spinal lesions were considered potential leak sites and were targeted for EBP. For the remaining 4 patients who did not have definite spinal lesions around the thecal sac, leak site determination was based primarily on the contrast gradient hypothesis. The authors hypothesized that the concentration of extradural contrast medium would be the greatest and the same as that of intradural contrast medium at the leak site but that it would decrease with increased distance from the leak site according to the contrast gradient. Epidural blood patch was placed at the level of spinal lesions and/or of the greatest and same concentration of contrast medium between the intradural and extradural spaces. For 10 of the 12 patients, the orthostatic headaches decreased significantly within a week of EBP and disappeared within a month. For the remaining 2 patients, headaches persisted and medical treatment was required for several months. For 3 patients, thick chronic subdural hematomas caused severe headaches and/or disturbed consciousness because of the mass effect of the hematomas, which were removed by bur hole drainage surgery. For 1 patient, bur hole drainage before EBP on the day of admission to hospital resulted in subdural tension pneumocephalus. The patient's headache immediately disappeared after EBP, and the hematoma did not recur. The other 2 patients underwent EBP followed by bur hole drainage, which resulted in improvements and disappearance of the hematomas. Over the follow-up period (mean 39 months), no CSF leaks or chronic subdural hematomas had recurred in any patient after EBP; by the final follow-up visit, all patients had returned to their jobs. Conclusions The most significant finding of this study was that spinal ventral calcified or ossified lesions, which may be associated with a dural tear, were present in approximately 70% of patients. Targeted EBP to these lesions resulted in good outcomes.

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Section: Discussionmentioning

confidence: 86%

mentioning

confidence: 99%

Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Yoshida¹,

Takai²,

Taniguchi³

2014

SPI

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“…31 The success of blood patches varies from 52 to 87.1% and improves if the site of CSF leakage is identified, as was the case with this patient. 32,33 Persistent cases may require neurosurgical consultation for fibrin sealants or surgical repair. 34,35 The natural history and long-term outcomes of SIH are not well known as large prospective studies are lacking, likely due to the rarity of the condition and frequent misdiagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…Bedrest to avoid upright position 5,19 Oral or intravenous rehydration 5,19 Oral or intravenous caffeine 5,19,26,27 Oral glucocorticoids 28 Invasive therapies (neurosurgical or anesthesia consultation) Epidural glucocorticoids 29 Intrathecal saline infusion 30 Epidural blood patch 32,33 Epidural fibrin sealant 34 Surgical repair 35 CSF 5 cerebrospinal fluid; ED 5 emergency department.…”

Section: Conservative Therapies (Ed Interventions)mentioning

confidence: 99%

Spontaneous low cerebrospinal fluid pressure headache: an emergency medicine perspective

Ahn

Akincioğlu²,

Gulka³

et al. 2013

CJEM

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Spontaneous low cerebrospinal fluid pressure headaches are a rare but treatable cause of debilitating headaches. The condition is characterized by a postural headache in the absence of any recent spinal procedures and is exacerbated when upright and relieved when supine. Diagnosis and treatment are often delayed, however, due to a lack of recognition and awareness, as illustrated by this case report of a patient who had multiple emergency department visits before further investigations were sought. RÉ SUMÉUne diminution spontané e de la pression du liquide cé phalorachidien est une cause rare mais soignable de cé phalé es dé bilitantes. L'affection se caracté rise par des cé phalé es orthostatiques, en l'absence de toute intervention rachidienne ré cente, qui s'intensifient en position debout et s'atté nuent en position couché e. La pose du diagnostic et la mise en route du traitement sont souvent retardé es en raison d'un manque de reconnaissance de l'affection et de prise de conscience de son existence, comme en té moigne le pré sent exposé de cas d'une patiente qui a consulté à plusieurs reprises au service des urgences avant que ne soit entreprise une exploration approfondie.

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“…Targeting epidural blood patching to the site of leak (if found) is more likely to be successful in resolving CSF leaks. 6 Given our patient's severely altered cognition in addition to his headache, he was treated immediately with empiric lumbar epidural blood patching. Over the following 48 hours, he reported a dramatic decrease in headache and had increased spontaneous speech production and was more engaged with his surroundings.…”

Section: Go To Sectionmentioning

confidence: 99%

Clinical Reasoning: A 50-year-old man with headache and cognitive decline

Batra

Berkowitz

2015

Neurology

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A 50-year-old man presented with headache and cognitive decline 10 weeks after undergoing matcheddonor peripheral blood stem cell transplantation for treatment of mixed-phenotype acute leukemia. His pretransplant treatment included systemic chemotherapy (cyclophosphamide, daunorubicin, vincristine, prednisone, L-asparaginase, dasatinib, and cytarabine), intrathecal chemotherapy (methotrexate), and total body irradiation. His posttransplant course had been complicated by cutaneous graft-vshost disease. Over 1 month, he developed holocephalic, throbbing, temporal headache worse when standing and reported feeling confused. His family members reported progressively withdrawn affect, depressed mood, and decreased spontaneous activity. Before his illness, he worked in a cognitively demanding profession with no history of cognitive deficit.On examination, he was arousable to voice but had difficulty sustaining alertness for more than a few seconds and was unable to state the days of the week backward. He was oriented to self, place, and month, but not year. He was able to follow simple 1-and 2-step commands but with profound psychomotor slowing and abulia. His cranial nerve examination was notable for mild anisocoria (right pupil being 1 mm larger than left and slightly sluggish in its response) but otherwise unremarkable including funduscopy. There was no weakness or incoordination, but all movements were performed slowly. Sensory and reflex examinations were normal. The patient was able to ambulate slowly with assistance.

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Spontaneous intracranial hypotension

Abstract: EBPs targeting CSF leaks can be safely placed under fluoroscopic guidance in patients with SIH and are more likely to be effective than blindly placed EBPs.

Cited by 146 publications

References 21 publications

Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Spontaneous low cerebrospinal fluid pressure headache: an emergency medicine perspective

Clinical Reasoning: A 50-year-old man with headache and cognitive decline

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