Cerebrospinal fluid leak presented with the C1-C2 sign caused by spinal canal stenosis: a case report.

BACKGROUND: Intracranial hypotension is a disorder characterized by low cerebrospinal fluid (CSF) pressure typically caused by loss of CSF. Although some mechanisms account for the CSF leakage have been elucidated, spinal canal stenosis has never been reported as a pathological cause of intracranial hypotension. C1-C2 sign is a characteristic imaging feature, which indicates CSF collection between the spinous processes of C1 and C2, occasionally observed on magnetic resonance imaging (MRI) in patients with intracranial hypotension. CASE PRESENTATION: A 58-year-old man was presented to our institute with complaints of posterior cervical pain persisting for 3 months, along with numbness and muscle weakness of extremities. A fat suppression T2-weighted image of MRI illustrated fluid collection in the retrospinal region at C1-C2 level, and an 111In-DTPA cisternoscintigram clearly revealed the presence of CSF leakage into the same region. The MRI also showed stenosis in spinal canal at C3/4 level, and a computed tomography (CT) myelogram suggested a blockage at the same level. We gave a diagnosis as intracranial hypotension due to the CSF leakage, which might be caused by the spinal canal stenosis at C3/4 level. Despite 72 h of conservative therapy, a brain CT showed the development of bilateral subdural hematomas. We, therefore, performed burr-hole drainage of the subdural hematoma, blood-patch therapy at C1/2 level, and laminoplasty at C3-4 at the same time. Improvement of symptoms and imaging features which suggested the CSF leak and subdural hematoma were obtained post-operatively. CONCLUSION: The present case suggested the mechanism where the CSF leakage was revealed as fluid collection in the retrospinal region at C1-C2 level. Increased intradural pressure due to the spinal canal stenosis resulted in dural tear. CSF leaked into the epidural space and subsequently to the retrospinal region at C1-C2 level, due to the presence of spinal canal stenosis caudally as well as the vulnerability of the tissue structure in the retrospinal region at C1-C2 level. Thus, our theory supports the mechanisms of previously reported CSF dynamics associated to C1-C2 sign, and also, we suggest spinal canal stenosis as a novel etiology of intracranial hypotension.

[Efficacy of percutaneous vertebroplasty for multiple myeloma].

Multiple myeloma is commonly associated with bony lesions and skeletal destruction. Percutaneous vertebroplasty (PVP) was performed in five patients with multiple myeloma for vertebral body fractures. Four patients reported a decrease in their pain after the procedure, and in all patients an improvement in their performance status could be noted. Complications included fever in two patients. PVP can be safely and effectively performed in patients with vertebral body fractures caused by multiple myeloma.

[A case of idiopathic thoracic spinal cord herniation].

We report a case of idiopathic thoracic spinal cord herniation. A 63-year-old female came to our hospital complaining of a slowly progressive gait disturbance that began 5 years ago. She showed signs of a left dominant spastic paraparesis and sensory disturbance. Her left foot had already became a drop foot from 2 years ago. Magnetic resonance (MR) imaging and computed tomographic (CT) myelography demonstrated that the atrophic spinal cord had displaced to the ventral side with a dilated dorsal subarachnoid space at T2-3 level. Surgery was performed via T2-3 laminoplastic laminectomy. The ventral aspect of the spinal cord revealed a defect in the inner layer of the duplicated dura mater, into which the gliotic spinal cord herniated. The herniated spinal cord was repositioned and the dural defect was repaired using a GORE-TEX dura substitute. Postoperative course was uneventful. Although the patient showed marked improvement in the right lower limb, there was slight improvement in the left lower limb. The clinical symptoms of this disease are uncommon and progress slowly, and if left untreated will result in paraparesis. Therefore early diagnosis and operation is important to prevent the progression of symptoms and to achieve a satisfactory outcome.

Fast inversion recovery magnetic resonance imaging with the real reconstruction method: a diagnostic tool for cerebral gliomas.

The fast inversion recovery (IR) technique was evaluated for the localization of gliomas. Fast IR imaging with real reconstruction and T1-weighted spin echo (SE) imaging before and after contrast administration were performed in 20 patients with gliomas. The tumor-to-white matter contrast ratio (TWCR), tumor-to-gray matter contrast ratio (TGCR), tumor-to-white matter contrast-to-noise ratio (TWCNR), and tumor-to-gray matter contrast-to-noise ratio (TGCNR) were calculated and compared. Fast IR imaging visualized tumors with significantly higher TWCR, TGCR, TWCNR, and TGCNR values (p < 0.01) than those for T1-weighted SE imaging. In particular, fast IR imaging clearly revealed seven non-enhanced tumors that were poorly visualized on T1-weighted SE imaging. Fast IR imaging showed a similar TGCR and significantly higher TWCR (p < 0.01) compared to T1-weighted SE imaging with contrast medium in 13 enhanced tumors. However, fast IR imaging showed similar TWCNR and lower TGCNR compared to T1-weighted SE imaging with contrast medium. The fast IR technique can discriminate tumors from normal cerebral tissues with high contrast and without the use of contrast medium. This technique is extremely useful for the localization of non-enhanced tumors.