Spontaneous Intracranial Hypotension: Atypical Radiologic Appearances, Imaging Mimickers, and Clinical Look-Alikes

Bond, Kamila M.; Benson, John C.; Cutsforth‐Gregory, Jeremy K.; Kim, D.K.; Diehn, Felix E.; Carr, Carrie M.

doi:10.3174/ajnr.a6637

Cited by 26 publications

(25 citation statements)

References 91 publications

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“…The statement “Having the patient perform a modified Valsalva maneuver can be helpful in identifying a rhinology source for a CSF leak,” did not reach consensus. Performing a modified Valsalva maneuver was even considered to be dangerous outside the operation theatre because it can lead, in cases of large defects, to pneumocephalus 26, 27 …”

Section: Discussionmentioning

confidence: 99%

“…Performing a modified Valsalva maneuver was even considered to be dangerous outside the operation theatre because it can lead, in cases of large defects, to pneumocephalus. 26,27 Investigations 29,30 will localize the defect. At the same time, they will identify indirect signs of IIH such as empty sella, arachnoid pits, skull-base thinning, 31 and tortuous optic nerves with widened subarachnoid space32 Both nuclear cisternogram and CT cisternography do not provide a benefit over simple HRCT/heavily-weighted T2 MRI; however, they are more invasive, less sensitive, and associated with more complications, as shown in a recent metanalysis.…”

Section: History and Clinical Examinationmentioning

confidence: 99%

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International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

Georgalas

Oostra

Ahmed

et al. 2020

Int Forum Allergy Rhinol

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Background The association between spontaneous cerebrospinal fluid CSF leak/rhinorrhea and idiopathic intracranial hypertension IIH has been increasingly recognized over the last years However considerable variability of opinion regarding the assessment investigations and management of patients with spontaneous CSF rhinorrhea remains Methods A consensus group was formed from experts from Europe Asia Australia South and North America Following literature review and open discussions with members of the panel a set of statements was produced A modified Delphi method was used to refine expert opinion with rounds of questionnaires and a consensus group meeting in Santo-Rhino meeting in September Results Fi y statements of total on spontaneous CSF leak and IIH reached consensus In of statements the median response was strongly agree and in the remaining statements the median response was agree Eleven statements were excluded because they did not reach consensus and one new statement was added during SantoRhino meeting The final statements refer to patient history and clinical examination "History taking should include presence of headache tinnitus and visual defects" investigations role of Thin Slice Computed Tomography and CISS/FLAIR sequences in Magnetic Resonance Imaging principles of management watchful waiting or measures to reduce ICP are supplementary but cannot subsitute surgical closure surgical technique intraoperative early postoperative and long term management Conclusion We present fi y consensus statements on the diagnosis investigation and management of spontaneous CSF rhinorrhea based on the currently available evidence and expert opinion Although by no means comprehensive and final we believe they can contribute to the standardization of clinical practice Early diagnosis prompt surgical closure of the defect assesment for and treatment of potentially co-existing idiopathic intracranial hypertension in a comprehensive multidisciplinary approach are essential in order to successfully manage spontaneous CSF rhinorrhea reduce associated morbidity and prevent recurrence

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Section: Discussionmentioning

confidence: 99%

Section: History and Clinical Examinationmentioning

confidence: 99%

International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

Georgalas

Oostra

Ahmed

et al. 2020

Int Forum Allergy Rhinol

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“…The most characteristic features of IH on intracranial MR (magnetic resonance) imaging include diffuse pachymeningeal enhancement and “brain sag” ( 9 , 10 ). Sagging of the brain can cause a subdural hematoma or hygroma, kinking of the midbrain and pons toward the clivus, lessening of the distance (e.g.,) from the optic chiasm to the pituitary gland, and tension on the cranial nerves ( 3 ).…”

Section: Discussionmentioning

confidence: 99%

Seizures and Consciousness Disorder Secondary to Intracranial Hypotension After Spinal Surgery: A Case Report and Literature Review

Xiang²

2022

Front. Neurol.

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RationaleCerebrospinal fluid (CSF) leakage is a common condition after spinal surgery and is also the most common cause of intracranial hypotension. Intracranial hypotension (IH) is typically characterized by an orthostatic headache with associated nausea, vomiting, tinnitus, vertigo, hypoacusis, neck stiffness, and photophobia. There have been limited case reports describing surgery-associated IH presenting with seizures and disorder of consciousness. Due to the atypia of symptoms, these clinical manifestations are usually ignored or even misdiagnosed. As a result, clinicians face a significant challenge in detecting IH early and understanding its various clinical presentations. Meanwhile, we summarize the cases of IH presenting as seizures in recent years, including its clinical characteristics and effective treatment, which will be very helpful for the early diagnosis of IH.Patient concernsA 72-year-old Chinese male patient developed status epilepticus, a disorder of consciousness, and quadriplegia when he finished spinal surgery, although he had no previous seizures or any seizure risk factors.DiagnosisAfter MRI and CT examination, subdural hygromas were found under both sides of the skull, and combined with the clinical manifestations of the patient, intracranial hypotension due to cerebrospinal fluid leakage was diagnosed.InterventionsIn the early stage, we carried out strict perioperative critical care for the patient. Trendelenburg position was conducted to relieve intracranial hypotension. The dural repair surgery was performed after the diagnosis of CSF leakage.OutcomesSeizures in the patient were resolved. Three months after discharge, he was gradually returning to normal life.LessonsOne possible cause of unexplained seizures and disorder of consciousness after spinal surgery is cerebrospinal fluid leakage associated with intracranial hypotension syndrome. Trendelenburg position and dural repair surgery are effective ways to relieve intracranial hypotension and associated symptoms. Better awareness of the association between IH (intracranial hypotension) and seizures may help us improve early recognition of the syndrome.

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“…For example, increased SIH symptom duration has been associated with resolution of pachymeningeal enhancement 11. Radiographic mimickers of SIH, such as Chiari malformation, further complicate the diagnostic process 12. It has been especially difficult to correlate specific symptoms and treatment effects with brain MRI findings.…”

Section: Introductionmentioning

confidence: 99%

Natural history of spontaneous intracranial hypotension: a clinical and imaging study

Williams

Brinjikji

Cutsforth‐Gregory

2022

J NeuroIntervent Surg

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BackgroundAlthough spontaneous intracranial hypotension (SIH) is well studied, there are few studies of the clinical and imaging history of SIH without interventional treatments. For example, what is the natural history of those who are untreated or treated only with conservative measures?ObjectiveTo conduct a retrospective study examining changes in imaging findings for patients with SIH without interventional treatments and to study associations between imaging findings and clinical symptoms.MethodsIncluded patients had a clinical diagnosis of SIH, were seen at Mayo Clinic between 1999 and 2021, had a brain MRI scan indicating SIH (Bern score), and had a brain MRI scan 6 or more months later without intervening leak-related interventional treatment. Bern scores were assigned for the first and last MRI scans prior to treatment. Patients were also grouped into three qualitative categories: overall improvement of symptoms, stable symptoms, or worsened symptoms based on patient report during the clinical visit at the time of the follow-up brain MRI scan.ResultsAmong 46 patients with untreated SIH, the Bern score improved over time in 11 (24%), was stable in 30 (65%), and worsened in 5 (11%). Two patients (4.3%) showed complete resolution of all abnormalities by the Bern scoring criteria. Symptoms improved in 7 (15%), were stable in 29 (63%), and worsened in 10 (22%).ConclusionsIn patients with brain MRI evidence of SIH, almost 25% demonstrated radiographic improvement, and 15% reported clinical improvement, during at least 6 months of observation or conservative treatment. Most had stable, persistent MRI abnormalities and symptoms when SIH was untreated.

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Spontaneous Intracranial Hypotension: Atypical Radiologic Appearances, Imaging Mimickers, and Clinical Look-Alikes

Cited by 26 publications

References 91 publications

International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

Seizures and Consciousness Disorder Secondary to Intracranial Hypotension After Spinal Surgery: A Case Report and Literature Review

Natural history of spontaneous intracranial hypotension: a clinical and imaging study

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