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1.
World Neurosurg ; 187: 294-303, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38970200

ABSTRACT

The confirmation of cerebrospinal fluid (CSF) leaks in the setting of spontaneous intracranial hypotension (SIH) by imaging involves a growing toolset of multimodal advanced spinal and skull base imaging techniques, for which exists a unique set of challenges for each CSF leak type. Furthermore, the repertoire of minimally invasive CSF leak treatment beyond nontargeted epidural blood patch administration has grown widely, with varied practices across institutions. This review describes current diagnostic imaging and treatment modalities as they apply to the challenges of CSF leak localization and management.


Subject(s)
Cerebrospinal Fluid Leak , Intracranial Hypotension , Minimally Invasive Surgical Procedures , Humans , Cerebrospinal Fluid Leak/therapy , Cerebrospinal Fluid Leak/diagnostic imaging , Cerebrospinal Fluid Leak/surgery , Intracranial Hypotension/therapy , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/etiology , Minimally Invasive Surgical Procedures/methods , Blood Patch, Epidural/methods , Magnetic Resonance Imaging
2.
AJNR Am J Neuroradiol ; 45(7): 951-956, 2024 Jul 08.
Article in English | MEDLINE | ID: mdl-38871369

ABSTRACT

BACKGROUND AND PURPOSE: Spinal CSF leaks cause spontaneous intracranial hypotension. Several types of leaks have been identified, and one of these types is the lateral dural tear. Performing myelography with the patient in the decubitus position allows precise characterization of these leaks. The purpose of the current study was to describe the different variants of spontaneous lateral CSF leaks. MATERIALS AND METHODS: This retrospective cohort study included a consecutive group of patients with spontaneous intracranial hypotension and lateral CSF leaks who underwent digital subtraction myelography in the decubitus position and underwent surgery to repair the CSF leak between July 2018 and June 2023. RESULTS: The mean age of the 53 patients (37 women and 16 men) was 35.5 years. Three different variants of lateral CSF leak could be identified. Forty-nine patients (92.5%) had a lateral dural tear associated with the nerve root sleeve. The dural tear was at the axilla of the nerve root sleeve in 36 patients (67.9%) and at the shoulder in 13 patients (24.5%). Four patients (7.5%) had a lateral dural tear at the level of the pedicle that was not associated with the nerve root sleeve. Findings on digital subtraction myelography were concordant with intraoperative findings in all patients. An extradural CSF collection was seen in all patients with a lateral dural tear associated with the nerve root sleeve but in only 2 of the 4 patients with the pedicular variant of a lateral dural tear. CONCLUSIONS: We identified 3 variants of spontaneous lateral dural tears. Most lateral dural tears are associated with extradural CSF collections and arise from either the axilla (67.9%) or the shoulder (24.5%) of the nerve root sleeve. Lateral dural tears at the level of the pedicle (7.5%) not associated with the nerve root sleeve are uncommon and may require specialized imaging for their detection.


Subject(s)
Cerebrospinal Fluid Leak , Intracranial Hypotension , Myelography , Humans , Female , Male , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/etiology , Adult , Retrospective Studies , Cerebrospinal Fluid Leak/diagnostic imaging , Cerebrospinal Fluid Leak/etiology , Myelography/methods , Middle Aged , Dura Mater/diagnostic imaging , Young Adult , Aged
3.
AJNR Am J Neuroradiol ; 45(7): 961-964, 2024 Jul 08.
Article in English | MEDLINE | ID: mdl-38697791

ABSTRACT

Spontaneous intracranial hypotension is characterized by symptoms of low intracranial CSF volume due to various mechanisms of CSF leakage. One such mechanism is a CSF-venous fistula, treatable with transvenous embolization resulting in substantial radiographic and clinical improvement. However, the exact mechanisms underlying these improvements, including the potential involvement of the glymphatic system, remain unclear. To noninvasively assess glymphatic clearance in spontaneous intracranial hypotension, we used an advanced MR imaging technique called the DTI along the perivascular spaces in 3 patients with CSF-venous fistula before and after embolization. All 3 patients with spontaneous intracranial hypotension initially had low glymphatic flow, which improved postembolization. Two patients with symptomatic improvement exhibited a more substantial increase in glymphatic flow compared with a patient with minimal improvement. These findings suggest a possible link between cerebral glymphatics in spontaneous intracranial hypotension pathophysiology and symptomatic improvement, warranting larger studies to explore the role of the glymphatic system in spontaneous intracranial hypotension.


Subject(s)
Embolization, Therapeutic , Glymphatic System , Intracranial Hypotension , Humans , Embolization, Therapeutic/methods , Glymphatic System/diagnostic imaging , Glymphatic System/physiopathology , Male , Intracranial Hypotension/therapy , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/physiopathology , Intracranial Hypotension/etiology , Female , Middle Aged , Adult , Treatment Outcome , Aged
4.
AJNR Am J Neuroradiol ; 45(7): 957-960, 2024 Jul 08.
Article in English | MEDLINE | ID: mdl-38697794

ABSTRACT

BACKGROUND AND PURPOSE: CSF venous fistula leads to spontaneous intracranial hypotension. The exact mechanisms underlying the development of CSF venous fistula remain unclear: Some researchers have postulated that underlying chronic intracranial hypertension may lead to damage to spinal arachnoid granulations, given that many patients with CSF venous fistulas have an elevated body mass index (BMI). However, individuals with higher BMIs are also more prone to spinal degenerative disease, and individuals with CSF venous fistulas also tend to be older. CSF venous fistula tends to occur in the lower thoracic spine, the most frequent location of thoracic degenerative changes. The current study aimed to examine whether CSF venous fistulas are more likely to occur at spinal levels with degenerative changes. MATERIALS AND METHODS: Forty-four consecutive patients with CSF venous fistulas localized on dynamic CT myelography were included in analyses. Whole-spine CT was scrutinized for the presence of degenerative changes at each spinal level. The proportion of levels positive for CSF venous fistula containing any degenerative findings was compared to levels without CSF venous fistula using the Fisher exact test. The Pearson correlation coefficient was calculated to explore the association between the burden of degenerative disease and BMI and age and between BMI and opening pressure. RESULTS: Forty-four patients with 49 total CSF venous fistulas were analyzed (5 patients had 2 CSF venous fistulas). Mean patient age was 62.3 (SD, 9.5) years. Forty-seven CSF venous fistulas were located in the thoracic spine; 1, in the cervical spine; and 1, in the lumbar spine. Within the thoracic spine, 39/49 (79.6%) fistulas were located between levels T7-8 and T12-L1. Forty-four of 49 (89.8%) CSF venous fistulas had degenerative changes at the same level. The levels without CSF venous fistulas demonstrated degenerative changes at 694/1007 (68.9%) total levels. CSF venous fistulas were significantly more likely to be present at spinal levels with associated degenerative changes (OR = 4.03; 95% CI, 1.58-10.27; P = .001). Age demonstrated a positive correlation with the overall burden of degenerative disease (correlation coefficient: 0.573, P < .001), whereas BMI did not (correlation coefficient: 0.076, P = .625). There was a statistically significant positive correlation between BMI and opening pressure (correlation coefficient: 0.321, P = .03). CONCLUSIONS: Results suggest a potential association between spinal degenerative disease and development of CSF venous fistula.


Subject(s)
Intracranial Hypotension , Osteoarthritis, Spine , Tomography, X-Ray Computed , Humans , Middle Aged , Male , Female , Aged , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/complications , Osteoarthritis, Spine/complications , Osteoarthritis, Spine/diagnostic imaging , Myelography , Adult
5.
Neurology ; 102(12): e209449, 2024 Jun 25.
Article in English | MEDLINE | ID: mdl-38820488

ABSTRACT

BACKGROUND AND OBJECTIVES: Spinal CSF leaks lead to spontaneous intracranial hypotension (SIH). While International Classification of Headache Disorders, Third Edition (ICHD-3) criteria necessitate imaging confirmation or low opening pressure (OP) for SIH diagnosis, their sensitivity may be limited. We offered epidural blood patches (EBPs) to patients with symptoms suggestive of SIH, with and without a documented low OP or confirmed leak on imaging. This study evaluates the efficacy of this strategy. METHODS: We conducted a prospective cohort study with a nested case-control design including all patients who presented to a tertiary headache clinic with clinical symptoms of SIH who completed study measures both before and after receiving an EBP between August 2016 and November 2018. RESULTS: The mean duration of symptoms was 8.7 ± 8.1 years. Of 85 patients assessed, 69 did not meet ICHD-3 criteria for SIH. At an average of 521 days after the initial EBP, this ICHD-3-negative subgroup experienced significant improvements in Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical Health score of +3.3 (95% CI 1.5-5.1), PROMIS Global Mental Health score of +1.8 (95% CI 0.0-3.5), Headache Impact Test (HIT)-6 head pain score of -3.8 (95% CI -5.7 to -1.8), Neck Disability Index of -4.8 (95% CI -9.0 to -0.6) and PROMIS Fatigue of -2.3 (95% CI -4.1 to -0.6). Fifty-four percent of ICHD-3-negative patients achieved clinically meaningful improvements in PROMIS Global Physical Health and 45% in HIT-6 scores. Pain relief following lying flat prior to treatment was strongly associated with sustained clinically meaningful improvement in global physical health at an average of 521 days (odds ratio 1.39, 95% CI 1.1-1.79; p < 0.003). ICHD-3-positive patients showed high rates of response and previously unreported, treatable levels of fatigue and cognitive deficits. DISCUSSION: Patients who did not conform to the ICHD-3 criteria for SIH showed moderate rates of sustained, clinically meaningful improvements in global physical health, global mental health, neck pain, fatigue, and head pain after EBP therapy. Pre-treatment improvement in head pain when flat was associated with later, sustained improvement after EBP therapy among patients who did not meet the ICHD-3 criteria. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that epidural blood patch is an effective treatment of suspected CSF leak not conforming to ICHD-3 criteria for SIH.


Subject(s)
Blood Patch, Epidural , Cerebrospinal Fluid Leak , Intracranial Hypotension , Humans , Female , Male , Blood Patch, Epidural/methods , Middle Aged , Adult , Cerebrospinal Fluid Leak/therapy , Intracranial Hypotension/therapy , Prospective Studies , Case-Control Studies , Treatment Outcome , Cohort Studies , Patient Reported Outcome Measures
6.
Int J Obstet Anesth ; 59: 103996, 2024 Aug.
Article in English | MEDLINE | ID: mdl-38719763

ABSTRACT

Intracranial hypotension can cause persistent and severe orthostatic headaches. It is often the result of cerebrospinal fluid leakage secondary to iatrogenic causes. It can also happen spontaneously. Diagnosing and managing severe orthostatic headaches associated with intracranial hypotension can be challenging, particularly during late pregnancy. This case describes a parturient at 30 weeks' gestation who presented with severe headaches due to intracranial hypotension caused by dural defects and cerebrospinal fluid venous fistula. She was managed with serial non-targeted epidural blood patching as a bridging remedy. This allowed further fetal maturity before delivery and definitive management of the dural leakage after delivery.


Subject(s)
Blood Patch, Epidural , Headache , Intracranial Hypotension , Humans , Female , Pregnancy , Blood Patch, Epidural/methods , Intracranial Hypotension/therapy , Intracranial Hypotension/complications , Headache/etiology , Headache/therapy , Adult , Pregnancy Complications/therapy , Pregnancy Trimester, Third
7.
Neurosurg Clin N Am ; 35(3): 311-318, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38782524

ABSTRACT

Cerebrospinal fluid-venous fistulas (CSFVFs) were first described in 2014 and have since become an increasingly diagnosed cause of spontaneous intracranial hypotension due to increased clinical recognition and advancements in diagnostic modalities. In this review, the authors discuss CSFVF epidemiology, the variety of clinical presentations, the authors' preferred diagnostic approach, recent advancements in diagnostic methods, treatment options, current challenges, and directions of future research.


Subject(s)
Intracranial Hypotension , Humans , Intracranial Hypotension/therapy , Intracranial Hypotension/diagnosis , Intracranial Hypotension/diagnostic imaging , Cerebral Veins/diagnostic imaging , Vascular Fistula/diagnosis , Cerebrospinal Fluid
8.
Neuroradiology ; 66(7): 1235-1238, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38755334

ABSTRACT

Neurofibromatosis type 1 (NF1) is a multisystem neurocutaneous disorder. Scoliosis and dural ectasia are features of the associated mesodermal dysplasia. Lateral thoracic meningoceles can develop in NF1 and progressively enlarge due to cerebrospinal fluid (CSF) pulsations. Large meningoceles can cause compressive symptoms in the thorax. We are reporting a case of a NF1 presenting with acute onset respiratory distress, who also had chronic orthostatic headaches. CT chest showed unruptured enlarging bilateral lateral thoracic meningoceles causing lung compression. MRI of the brain and spine showed features of CSF hypotension, explaining the headaches. CSF hypotension with unruptured meningoceles is extremely rare. Management of the condition is challenging since surgical removal is prone to complications due to underlying mesodermal abnormalities. Cystoperitoneal shunting to relieve lung compression may worsen CSF hypotension. A shunt with a programmable valve allowed controlled drainage and successfully relieved lung compression without worsening of orthostatic headaches in our case.


Subject(s)
Meningocele , Neurofibromatosis 1 , Humans , Neurofibromatosis 1/complications , Meningocele/diagnostic imaging , Meningocele/complications , Meningocele/surgery , Magnetic Resonance Imaging , Tomography, X-Ray Computed , Male , Female , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/etiology , Hypotension/etiology , Thoracic Vertebrae/diagnostic imaging , Thoracic Vertebrae/surgery , Diagnosis, Differential , Rare Diseases
9.
Headache ; 64(4): 460-463, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38613228

ABSTRACT

Spontaneous intracranial hypotension (SIH) commonly results from ventral spinal cerebrospinal fluid (CSF) leaks and epidural patches are advocated as first-line treatment. Complications such as superficial siderosis can arise but have previously been reported only in the context of long-term persistent, ongoing, CSF leak and SIH. We report a case of a patient with SIH from a ventral spinal CSF leak that was treated with epidural patching and experienced complete resolution of SIH. Four years later SIH symptoms recurred, and brain magnetic resonance imaging unexpectedly showed the interval accumulation of hemosiderin pigmentation on the cerebellum and brainstem during the period when the patient was without symptoms of SIH. This case uniquely demonstrates the progression of superficial siderosis despite the apparent resolution of SIH. Our findings suggest two divergent pathophysiological outcomes from spinal ventral dural tear: (1) CSF loss causing SIH; and (2) persistent low-level bleeding arising from the spinal dural tear leading to superficial siderosis. These divergent pathophysiologies had a discordant response to epidural patching. Epidural patching successfully treated the SIH but did not prevent the progression of superficial siderosis, indicating that some patients may require more than epidural patching despite symptom resolution. This case highlights the need for post-treatment monitoring protocols in patients with ventral spinal CSF leaks and SIH and raises important questions about the adequacy of epidural patching in certain SIH cases arising from ventral spinal CSF leak.


Subject(s)
Blood Patch, Epidural , Intracranial Hypotension , Adult , Humans , Male , Cerebrospinal Fluid Leak/complications , Cerebrospinal Fluid Leak/therapy , Cerebrospinal Fluid Leak/etiology , Disease Progression , Intracranial Hypotension/therapy , Intracranial Hypotension/complications , Intracranial Hypotension/etiology , Intracranial Hypotension/diagnostic imaging , Magnetic Resonance Imaging , Siderosis/complications
10.
World Neurosurg ; 188: 78, 2024 Aug.
Article in English | MEDLINE | ID: mdl-38663740

ABSTRACT

Cerebrospinal fluid venous fistulas (CSF-VFs) are an uncommon, yet increasingly recognized, cause of spontaneous intracranial hypotension.1-5 The workup involves magnetic resonance imaging (MRI) of the brain with and without contrast and MRI of the neuroaxis without contrast before dynamic myelography, either computed tomography or digital subtraction.6 The present case of an older woman with symptomatic intracranial hypotension is notable for the specific appearance of CSF-VFs on digital spinal myelography (Video 1). Among her numerous perineural cysts, it was the "disappearing" or "empty" cyst from which the fistula originated. The diagnosis was made using a second lateral fluoroscopy view, not typically used in digital spinal myelography, which demonstrated emptying of contrast from the T6 perineural cyst into the segmental vein at this level, or the "empty cyst sign." The patient then underwent transvenous onyx embolization with resolution of her orthostatic headaches and improvement of contrast-enhanced MRI of the brain with the Bern score decreasing from 7 to 0 at 3 months of follow-up.7 Because transvenous embolization of CSF-VFs is a relatively new procedure, the long-term outcomes of the procedure are not yet known.


Subject(s)
Intracranial Hypotension , Myelography , Humans , Female , Myelography/methods , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/therapy , Intracranial Hypotension/complications , Intracranial Hypotension/etiology , Embolization, Therapeutic/methods , Aged , Magnetic Resonance Imaging , Vascular Fistula/diagnostic imaging , Vascular Fistula/complications , Cerebrospinal Fluid
11.
J Neurol ; 271(7): 4336-4347, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38643444

ABSTRACT

BACKGROUND AND OBJECTIVE: Spontaneous intracranial hypotension (SIH) is an underdiagnosed disease. To depict the accurate diagnosis can be demanding; especially the detection of CSF-venous fistulas poses many challenges. Potential dynamic biomarkers have been identified through non-invasive phase-contrast MRI in a limited subset of SIH patients with evidence of spinal longitudinal extradural collection. This study aimed to explore these biomarkers related to spinal cord motion and CSF velocities in a broader SIH cohort. METHODS: A retrospective, monocentric pooled-data analysis was conducted of patients suspected to suffer from SIH who underwent phase-contrast MRI for spinal cord and CSF velocity measurements at segment C2/C3 referred to a tertiary center between February 2022 and June 2023. Velocity ranges (mm/s), total displacement (mm), and further derivatives were assessed and compared to data from the database of 70 healthy controls. RESULTS: In 117 patients, a leak was located (54% ventral leak, 20% lateral leak, 20% CSF-venous fistulas, 6% sacral leaks). SIH patients showed larger spinal cord and CSF velocities than healthy controls: e.g., velocity range 7.6 ± 3 mm/s vs. 5.6 ± 1.4 mm/s, 56 ± 21 mm/s vs. 42 ± 10 mm/s, p < 0.001, respectively. Patients with lateral leaks and CSF-venous fistulas exhibited an exceptionally heightened level of spinal cord motion (e.g., velocity range 8.4 ± 3.3 mm/s; 8.2 ± 3.1 mm/s vs. 5.6 ± 1.4 mm/s, p < 0.001, respectively). CONCLUSION: Phase-contrast MRI might become a valuable tool for SIH diagnosis, especially in patients with CSF-venous fistulas without evidence of spinal extradural fluid collection.


Subject(s)
Biomarkers , Intracranial Hypotension , Magnetic Resonance Imaging , Humans , Intracranial Hypotension/diagnostic imaging , Intracranial Hypotension/cerebrospinal fluid , Female , Male , Middle Aged , Retrospective Studies , Adult , Biomarkers/cerebrospinal fluid , Aged , Spinal Cord/diagnostic imaging , Cerebrospinal Fluid Leak/diagnostic imaging
12.
Neuroradiology ; 66(8): 1335-1344, 2024 Aug.
Article in English | MEDLINE | ID: mdl-38658472

ABSTRACT

PURPOSE: To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility. METHODS: In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen's kappa statistics, interobserver agreement was assessed. RESULTS: In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39). CONCLUSION: The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.


Subject(s)
Contrast Media , Intracranial Hypotension , Magnetic Resonance Imaging , Meninges , Humans , Female , Male , Intracranial Hypotension/diagnostic imaging , Magnetic Resonance Imaging/methods , Retrospective Studies , Middle Aged , Adult , Meninges/diagnostic imaging , Meninges/pathology , Aged , Sensitivity and Specificity , Feasibility Studies , Image Enhancement/methods
13.
Zhonghua Yi Xue Za Zhi ; 104(13): 1021-1027, 2024 Apr 02.
Article in Chinese | MEDLINE | ID: mdl-38561296

ABSTRACT

Spinal cerebrospinal fluid leakage is a common cause of spontaneous intracranial hypotension. Traditional treatment methods include conservative treatment and surgical treatment, but conservative treatment is ineffective for some patients, while surgical treatment is rarely used in clinical practice due to severe trauma. Minimally invasive surgery at appropriate time is an important method to handlecerebrospinal fluid leakage. Therefore, the Group of Headache and Facial Pain, Pain Branch of Chinese Medical Association formulated this technical specification of epidural blood patch for treatment of normal dural sac tension spinal cerebrospinal fluid leakage. This paper mainly discusses the concept and mechanism, indications and contraindications, operation methods, complications and treatment methods of epidural blood patch in order to improve clinical efficacy, reduce neuralsystem complications and reduce the incidence of adverse events.


Subject(s)
Blood Patch, Epidural , Intracranial Hypotension , Humans , Blood Patch, Epidural/adverse effects , Cerebrospinal Fluid Leak/complications , Cerebrospinal Fluid Leak/therapy , Intracranial Hypotension/therapy , Intracranial Hypotension/etiology , Treatment Outcome , Facial Pain/complications , Facial Pain/therapy , Magnetic Resonance Imaging
14.
Neurol Clin ; 42(2): 473-486, 2024 May.
Article in English | MEDLINE | ID: mdl-38575260

ABSTRACT

Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks. New evidence indicates that a lumbar puncture may not be essential for diagnosing every patient with SIH. Spinal neuroimaging protocols used for diagnosing and localizing spinal cerebrospinal fluid leaks include brain/spinal MRI, computed tomography myelography, digital subtraction myelography, and radionuclide cisternography. Complications of SIH include subdural hematoma, cerebral venous thrombosis, and superficial siderosis. Treatment options encompass conservative management, epidural blood patches, and surgical interventions. The early application of epidural blood patches in all patients with SIH is suggested.


Subject(s)
Intracranial Hypotension , Humans , Intracranial Hypotension/diagnosis , Intracranial Hypotension/diagnostic imaging , Cerebrospinal Fluid Leak/diagnostic imaging , Cerebrospinal Fluid Leak/etiology , Magnetic Resonance Imaging/methods , Tomography, X-Ray Computed/methods , Neuroimaging , Headache/etiology
15.
J Clin Neurosci ; 123: 118-122, 2024 May.
Article in English | MEDLINE | ID: mdl-38569382

ABSTRACT

Epidural blood patch (EBP)-the most effective treatment for intracranial hypotension (IH)-can be performed using the blind technique in the lateral position or under fluoroscopic guidance in the prone position. This study aimed to compare the effectiveness of EBP in patients with spontaneous intracranial hypotension (sIH) and iatrogenic intracranial hypotension (iIH) when performed with the blind technique in the lateral decubitus position or fluoroscopic guidance in the prone position. We reviewed IH patients who underwent EBP between January 2015 and September 2019 in a single hospital and divided them into two groups according to the type of IH. Of the 84 included patients, 36 had sIH and 48 had iIH. We compared the effectiveness of EBP using the two methods in each group. There was no significant difference in the effect of EBP between the patients with iIH (p > 0.05). For patients with sIH, fluoroscopic guidance in the prone position technique showed better improvement than the blind technique in the lateral decubitus position (p < 0.05). We observed similar outcomes after blind EBP versus fluoroscopic guidance EBP in patients with iIH. However, procedure-dependent differences were observed in patients with sIH. For patients with sIH, it would be effective to consider fluoroscopic EBP first. Further study is needed to investigate interactions between method of EBP and other factors that affect the effectiveness of EBP.


Subject(s)
Blood Patch, Epidural , Intracranial Hypotension , Humans , Blood Patch, Epidural/methods , Intracranial Hypotension/therapy , Intracranial Hypotension/diagnostic imaging , Female , Male , Fluoroscopy/methods , Middle Aged , Adult , Retrospective Studies , Treatment Outcome , Patient Positioning/methods , Aged
16.
Headache ; 64(4): 380-389, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38634709

ABSTRACT

OBJECTIVES: This study aimed to identify predictors for the recurrence of spontaneous intracranial hypotension (SIH) after epidural blood patch (EBP). BACKGROUND: Epidural blood patch is the main treatment option for SIH; however, the characteristics of patients who experience relapse after successful EBP treatment for SIH remain understudied. METHODS: In this exploratory, retrospective, case-control study, we included 19 patients with SIH recurrence after EBP and 36 age- and sex-matched patients without recurrence from a single tertiary medical institution. We analyzed clinical characteristics, neuroimaging findings, and volume changes in intracranial structures after EBP treatment. Machine learning methods were utilized to predict the recurrence of SIH after EBP treatment. RESULTS: There were no significant differences in clinical features between the recurrence and no-recurrence groups. Among brain magnetic resonance imaging signs, diffuse pachymeningeal enhancement and cerebral venous dilatation were more prominent in the recurrence group than no-recurrence group after EBP (14/19 [73%] vs. eight of 36 [22%] patients, p = 0.001; 11/19 [57%] vs. seven of 36 [19%] patients, p = 0.010, respectively). The midbrain-pons angle decreased in the recurrence group compared to the no-recurrence group after EBP, at a mean (standard deviation [SD]) of -12.0 [16.7] vs. +1.8[18.3]° (p = 0.048). In volumetric analysis, volume changes after EBP were smaller in the recurrence group than in the no-recurrence group in intracranial cerebrospinal fluid (mean [SD] -11.6 [15.3] vs. +4.8 [17.1] mL, p = 0.001) and ventricles (mean [SD] +1.0 [2.0] vs. +2.0 [2.5] mL, p = 0.003). Notably, the random forest classifier indicated that the model constructed with brain volumetry was more accurate in discriminating SIH recurrence (area under the curve = 0.80 vs. 0.52). CONCLUSION: Our study suggests that volumetric analysis of intracranial structures may aid in predicting recurrence after EBP treatment in patients with SIH.


Subject(s)
Blood Patch, Epidural , Intracranial Hypotension , Magnetic Resonance Imaging , Recurrence , Humans , Intracranial Hypotension/therapy , Intracranial Hypotension/diagnostic imaging , Female , Male , Retrospective Studies , Adult , Middle Aged , Case-Control Studies , Machine Learning
17.
AJNR Am J Neuroradiol ; 45(5): 662-667, 2024 05 09.
Article in English | MEDLINE | ID: mdl-38485194

ABSTRACT

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension is a condition resulting from a leak of CSF from the spinal canal arising independent of a medical procedure. Spontaneous intracranial hypotension can present with normal brain MR imaging findings and nonspecific symptoms, leading to the underdiagnosis in some patients and unnecessary invasive myelography in others who are found not to have the condition. Given the likelihood that spontaneous intracranial hypotension alters intracranial biomechanics, the goal of this study was to evaluate MR elastography as a potential noninvasive test to diagnose the condition. MATERIALS AND METHODS: We performed MR elastography in 15 patients with confirmed spontaneous intracranial hypotension from September 2022 to April 2023. Age, sex, symptom duration, and brain MR imaging Bern score were collected. MR elastography data were used to compute stiffness and damping ratio maps, and voxelwise modeling was performed to detect clusters of significant differences in mechanical properties between patients with spontaneous intracranial hypotension and healthy control participants. To evaluate diagnostic accuracy, we summarized each examination by 2 spatial pattern scores (one each for stiffness and damping ratio) and evaluated group-wise discrimination by receiver operating characteristic curve analysis. RESULTS: Patients with spontaneous intracranial hypotension exhibited significant differences in both stiffness and damping ratio (false discovery rate-corrected, Q < 0.05). Pattern analysis discriminated patients with spontaneous intracranial hypotension from healthy controls with an area under the curve of 0.97 overall, and the area under the curve was 0.97 in those without MR imaging findings of spontaneous intracranial hypotension. CONCLUSIONS: Results from this pilot study demonstrate MR elastography as a potential imaging biomarker and a noninvasive method for diagnosing spontaneous intracranial hypotension, including patients with normal brain MR imaging findings.


Subject(s)
Elasticity Imaging Techniques , Intracranial Hypotension , Magnetic Resonance Imaging , Humans , Intracranial Hypotension/diagnostic imaging , Elasticity Imaging Techniques/methods , Female , Male , Adult , Middle Aged , Magnetic Resonance Imaging/methods , Aged , Young Adult
18.
AJNR Am J Neuroradiol ; 45(5): 668-671, 2024 05 09.
Article in English | MEDLINE | ID: mdl-38485199

ABSTRACT

Photon-counting CT is an increasingly used technology with numerous advantages over conventional energy-integrating detector CT. These include superior spatial resolution, high temporal resolution, and inherent spectral imaging capabilities. Recently, photon-counting CT myelography was described as an effective technique for the detection of CSF-venous fistulas, a common cause of spontaneous intracranial hypotension. It is likely that photon-counting CT myelography will also have advantages for the localization of dural tears, a separate type of spontaneous spinal CSF leak that requires different myelographic techniques for accurate localization. To our knowledge, prior studies on photon-counting CT myelography have been limited to techniques for detecting CSF-venous fistulas. In this technical report, we describe our technique and early experience with photon-counting CT myelography for the localization of dural tears.


Subject(s)
Dura Mater , Intracranial Hypotension , Myelography , Tomography, X-Ray Computed , Intracranial Hypotension/diagnostic imaging , Humans , Myelography/methods , Dura Mater/diagnostic imaging , Tomography, X-Ray Computed/methods , Male , Female , Middle Aged , Photons
19.
Curr Pain Headache Rep ; 28(5): 395-401, 2024 May.
Article in English | MEDLINE | ID: mdl-38430310

ABSTRACT

PURPOSE OF REVIEW: Rebound intracranial hypertension (RIH) is a post-procedural treatment complication in patients with spontaneous intracranial hypotension (SIH) characterized by transient high-pressure headache symptoms. This article reviews the epidemiology, clinical features, risk factors, and treatment options for RIH. RECENT FINDINGS: This article discusses how changes in underlying venous pressure and craniospinal elastance can explain symptoms of RIH, idiopathic intracranial hypertension (IIH), and SIH. The pathophysiology of RIH provides a clue for how high and low intracranial pressure disorders, such as IIH and SIH, are connected on a shared spectrum.


Subject(s)
Intracranial Hypertension , Intracranial Hypotension , Humans , Intracranial Hypertension/physiopathology , Intracranial Hypertension/therapy , Intracranial Hypertension/complications , Intracranial Hypotension/therapy , Intracranial Hypotension/physiopathology , Intracranial Hypotension/diagnosis , Risk Factors , Pseudotumor Cerebri/physiopathology , Pseudotumor Cerebri/therapy , Pseudotumor Cerebri/diagnosis , Pseudotumor Cerebri/complications , Headache/physiopathology , Headache/etiology , Headache/therapy
20.
Neurology ; 102(7): e209256, 2024 Apr 09.
Article in English | MEDLINE | ID: mdl-38484224

ABSTRACT

Bibrachial amyotrophy signifies a clinical phenotype characterized by weakness in both upper extremities with preserved strength in the face, neck, and lower extremities. The underlying causes of bibrachial amyotrophy are broad. We report a patient exhibiting bibrachial amyotrophy who initially received a diagnosis of amyotrophic lateral sclerosis (ALS); however, his clinical course and NCS/EMG were atypical for ALS. Further evaluation demonstrated dural tears with CSF leak, resulting in a compressive extradural fluid collection, ventral myelopathy, and intracranial hypotension. Dural tear and ALS have overlapping features, including the manifestation of the bibrachial amyotrophy phenotype and the presence of T2 hyperintensities in the anterior horn cells, recognized by an "owl's eye" appearance on spine MRI. Clinical and radiologic vigilance is required to identify rare cases of dural tear causing ventral myelopathy that manifest as bibrachial amyotrophy.


Subject(s)
Amyotrophic Lateral Sclerosis , Intracranial Hypotension , Spinal Cord Diseases , Humans , Amyotrophic Lateral Sclerosis/diagnosis , Magnetic Resonance Imaging , Neck
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