Coupling of CSF and sagittal sinus pressure in adult patients with pseudotumour cerebri.

OBJECTIVE: Pseudotumour cerebri syndrome (PTCS including idiopathic intracranial hypertension) is characterised by the symptoms and signs of raised cerebrospinal fluid pressure (CSFp) in the absence of ventricular dilatation or an intracranial mass lesion. Its aetiology is unknown in the majority of cases but there is much evidence for impaired CSF absorption. Traditionally, sagittal sinus pressure has been considered to be independent of CSF pressure in adults. However, the discovery of stenoses of intracranial venous sinuses and introduction of venous sinus stenting has highlighted the importance of the venous drainage in PTCS. In this study, we have explored the relationship between CSFp and SSp before and during a CSF infusion test and during CSF drainage. MATERIALS AND METHODS: Ten patients (9 females:1 male) with PTCS underwent infusion studies in parallel with direct retrograde cerebral venography. Both SSp and CSFp were recorded at a baseline and during CSFp elevation in a course of a CSF infusion test. The drainage of CSF after the CSF infusion was performed in 7 patients. In 5 cases, jugular venous pressure was also measured. RESULTS: CSFp and SSp including their amplitudes correlated significantly and strongly both at baseline (R = 0.96; p = 0.001) and during infusion (R = 0.92; p = 0.0026). During drainage, this correlation was maintained until SSp reached a stable value, whereas CSFp continued to decrease. CONCLUSIONS: In this series of ten patients with PTCS, CSFp and SSp were coupled, both at baseline and during infusion. The implications of such coupling for the calculation of CSF outflow resistance are discussed.

Combined radiological and surgical management of spinal dural fistulas.

INTRODUCTION: Spinal Dural Fistulas (SDAVF) are the most common Spinal Vascular Malformation. The management of SDAVFs involves diagnosis and localisation with MRI and spinal angiography and subsequent embolisation or surgical interruption. We report our experience in treating these fistulas in which we undertake endovascular treatment, if technically feasible, with recourse to surgery only if occlusion is not possible. METHOD: This retrospective study reviews the management of 38 patients treated for SDAVFs over a 13-year period (1997-2010). Patient demographics, procedure and follow-up over a 6-12-month period (mean of approximately 10 months) were analysed and a qualitative assessment of patient outcome was made. RESULTS: Patient ages ranged from 20 to 86 (mean 63.5), with 27 male and 11 female patients. A total of 28 patients managed with a combination of embolisation and surgery report either with improved symptoms or a return to normal. The presence of bladder and bowel symptoms indicated more severe disability and their presence at presentation was associated with lack of improvement following treatment. CONCLUSIONS: We report a treatment strategy for SDAVF involving primary endovascular intervention and reserving surgery for those patients in whom endovascular treatment is not possible.