Spontaneous intracranial hypotension: analysis of 118 patients ' clinical characteristics / 中华神经科杂志

Objective:To summarize the clinical features, radiological characteristics, therapy, and outcome of patients with spontaneous intracranial hypotension (SIH).Methods:The general information, clinical manifestations, auxiliary examinations, treatment, and outcomes in consecutive patients of SIH hospitalized in the Xuanwu Hospital, Capital Medical University from November 2018 to October 2022 were analyzed.Results:A total of 118 patients with a female-to-male ratio of 5∶4 were included and the ages were 17.00-71.00[39.00(34.00,46.75)]years with a preponderance in the age of 30-49 years. Almost all patients had orthostatic headaches (117/118, 99.2%), accompanied by nausea (90/118, 76.3%), vomiting (70/118, 59.3%), neck stiffness (88/118, 74.6%), tinnitus (57/118, 48.3%), and ear fullness (57/118, 48.3%). Brain magnetic resonance imaging (MRI) showed dural enhancement (97/113, 85.8%), enlarged venous sinus (88/113, 77.9%), subdural fluid collection (46/113, 40.7%), decreased suprasellar cistern (86/113, 76.1%), effacement of the prepontine cistern (86/113, 76.1%), diminished mamillopontine distance (80/113, 70.8%). The cerebrospinal fluid (CSF) leaks were detected in 90.7% (107/118) of the patients by magnetic resonance myelography but 54.3% (25/46) and 52.6% (20/38) by CT myelography and magnetic resonance myelography with gadolinium. Lumber puncture found CSF pressure<60 mmH 2O (1 mmH 2O=0.009 8 kPa) in 18.4% (19/103) of patients, increased CSF red blood cell counts in 50.6% (44/87) of patients, CSF pleocytosis in 44.8% (39/87) of patients, increased CSF protein concentrations in 57.5% (50/87) of patients. The headache completely disappeared after conservative treatment in 24.6% (31/118) of patients and after a single targeted epidural blood patch in 89.7% (78/87) of patients. A rebound headache after epidural blood patch treatment occurred in 66.0% (58/87) of patients. Conclusions:The patients with SIH almost manifested with orthostatic headache, and brain MRI and magnetic resonance myelography were suggested in those patients instead of CSF pressure by lumber puncture. Targeted epidural blood patch was effective and safe in SIH patients.

Spontaneous intracranial hypotension caused by high-flow spinal cerebrospinal fluid leaks: analysis of 6 patients / 中华神经科杂志

Objective:To analyze the clinical features of 6 patients with spontaneous intracranial hypotension caused by high-flow spinal cerebrospinal fluid leaks.Methods:The clinical characteristics, auxiliary examinations, treatment, and outcomes in 6 patients of spontaneous intracranial hypotension caused by high-flow spinal cerebrospinal fluid leaks enrolled in the Xuanwu Hospital, Capital Medical University from February 2021 to April 2022 were retrospectively reviewed.Results:All the 6 patients had orthostatic headaches. Brain magnetic resonance imaging showed dural enhancement and brain sagging and magnetic resonance myelography showed longitudinal extradural collection in all the patients. The high-flow spinal cerebrospinal fluid leaks were demonstrated in upper thoracic segments by the dynamic myelography. The headache disappeared after conservative treatment in 2 patients and treatment with targeted epidural blood patch in 4 patients.Conclusions:The diagnosis of spontaneous intracranial hypotension caused by high-flow spinal cerebrospinal fluid leaks with typical orthostatic headache and brain magnetic resonance imaging and myelography findings is not difficult. However, the localization of the site of high-flow spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension depends on the dynamic myelography. Targeted epidural blood patch is effective, but conservative treatment does not always work.

Síndrome De Hipotensión Endocraneana Espontánea: Reporte De Un Caso Clínico / Spontaneous Intracranial Hypotension Syndrome: Clinic Case Report

La hipotensión intracraneal espontánea (SIH) es una patología con una incidencia anual aproximada de 5 por cada 100.000 personas al año, caracterizada clásicamente por cefalea ortostática comúnmente secundaria a una fuga espontánea de líquido cefalorraquídeo (LCR), pudiendo existir a su vez una amplia gama de síntomas asociados. El diagnóstico se centra en la clínica y en hallazgos típicos en la resonancia nuclear magnética (RM), sin embargo, según diversos estudios, puede corresponder a una patología subdiagnosticada por la dificultad que ha existido en definir criterios diagnósticos universales y un manejo terapéutico estandarizado, el cual varía inicialmente entre manejo médico conservador y/o parches de sangre epidural (PHE). Reportamos el caso de una paciente femenina de 51 años quien fue atendida en el Hospital Herminda Martin de Chillán donde se realizó el diagnóstico y tratamiento sintomático con PHE.

Spontaneous intracranial hypotension (SIH) is a pathology with an annual incidence of approximately 5 per 100,000 people per year, classically characterized by orthostatic headache commonly secondary to a spontaneous cerebrospinal fluid (CSF) leak, and there may also be a wide range of of associated symptoms. The diagnosis is centered on the clinic and on typical findings in magnetic resonance imaging (MRI), however, according to various studies, it may correspond to an underdiagnosed pathology due to the difficulty that has existed in defining universal diagnostic criteria and standardized therapeutic management. which initially varies between conservative medical management and/or epidural blood patches (PHE). We report the case of a 51-year-old female patient who was treated at the Herminda Martin de Chillán Hospital where the diagnosis and symptomatic treatment with PHE were made.

Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture / O calibre e o design da agulha estão associados ao risco de cefaleia pós-punção dural após punção lombar diagnóstica

Introduction:Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective:To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods:A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25 G or less and 2) greater than 25 G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results:141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (p=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (p=0.026). Conclusion:25 G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

Introdução: A cefaleia pós-punção dural (CPPD) é definida como uma cefaleia ortostática que se desenvolve nos primeiros dias após a realização de uma punção lombar e está relacionada ao extravasamento de líquido cefalorraquidiano (LCR) para o espaço peridural, resultando em hipovolemia do LCR e hipotensão. Os fatores de risco para CPPD ainda não são totalmente compreendidos. Objetivo:Avaliar o risco de CPPD relatada espontaneamente de acordo com o tamanho e tipo de agulha de punção lombar. Métodos: Foram incluídos 4.589 pacientes submetidos à punção lombar (PL) ambulatorial. Todas as coletas de LCR foram realizadas no Senne Liquor Diagnostico, laboratório especializado em coleta e análise de LCR. Os pacientes foram orientados a relatar por telefone à equipe médica do laboratório se apresentassem cefaleia ortostática nos primeiros 7 dias após a PL. Pacientes com cefaleia prévia foram orientados a relatar qualquer alteração no padrão de cefaleia durante o mesmo período. O calibre da agulha foi classificado em dois grupos: 1) 25 G ou menos e 2) maior que 25 G. Dois tipos de agulhas foram utilizados e comparados: 1) ponta de lápis e 2) Quincke. As comparações dos percentuais de notificações espontâneas de CPPD foram feitas por meio do teste do qui-quadrado. Resultados:141 pacientes (3,07%) relataram CPPD à equipe médica do laboratório. Agulhas de calibre 25G ou menos foram utilizadas em 31,8% dos casos. A porcentagem de pacientes que relataram HDP no grupo de agulhas 25G ou menos foi de 1,9% versus 3,6% no grupo de agulhas maiores que 25G (p=0,003). Agulhas com ponta de lápis foram utilizadas em 10,6% dos casos. O percentual de DPH no grupo ponta de lápis foi de 1,4% versus 3,2% no grupo Quincke (p=0,026). Conclusão: Agulhas de calibre 25 G ou mais fino, bem como agulhas tipo ponta de lápis reduziram significativamente o risco de HP relatado espontaneamente.

Spontaneous intracranial hypotension: a case report in the context of differential diagnosis of chronic headaches / Hipotensão intracraniana espontânea: relato de caso no contexto do diagnóstico diferencial de cefaleias crônicas

Spontaneous intracranial hypotension (SIH) is a rare and debilitating condition caused by decreased intracranial pressure, which occurs more frequently in females. SIH can have several causes, among them the spontaneous formation of cerebrospinal fluid venous fistula (CSF-venous fistula), which is primarily responsible for the appearance of postural headache. Orthostatic headache is diagnosed by CSF pressure < 6 mmHg associated with specific imaging findings. Other specific symptoms such as dizziness, reduced muscle strength, blurred vision and syncope and other more systemic symptoms such as fatigue, mental confusion and difficulty concentrating are commonly observed. Etiological investigation through imaging studies such as magnetic resonance imaging and dynamic tomography of myelography is necessary for diagnosis. Due to the debilitating condition, several therapeutic approaches have been developed, ranging from more conservative approaches, with observation and use of analgesics, to more invasive interventions such as surgical ligation, transvenous embolization and blood tamponade.

A hipotensão intracraniana espontânea (HIH) é uma condição rara e debilitante causada pela diminuição da pressão intracraniana, que ocorre com mais frequência em mulheres. A HIE pode ter diversas causas, entre elas a formação espontânea de fístula venosa do líquido cefalorraquidiano (fístula liquórica-venosa), principal responsável pelo aparecimento da cefaleia postural. A cefaleia ortostática é diagnosticada pela pressão liquórica < 6 mmHg associada a achados de imagem específicos. Outros sintomas específicos como tontura, redução da força muscular, visão turva e síncope e outros sintomas mais sistêmicos como fadiga, confusão mental e dificuldade de concentração são comumente observados. A investigação etiológica por meio de exames de imagem como ressonância magnética e tomografia dinâmica da mielografia é necessária para o diagnóstico. Devido ao quadro debilitante, diversas abordagens terapêuticas têm sido desenvolvidas, desde abordagens mais conservadoras, com observação e uso de analgésicos, até intervenções mais invasivas como ligadura cirúrgica, embolização transvenosa e tamponamento sanguíneo.

Headache attributed to spontaneous intracranial hypotension and associated possible causes / Cefaleia atribuída à hipotensão intracraniana espontânea e possíveis causas associadas

Bem Junior and coworkers published a very interesting and opportunely case report on spontaneous intracranial hypotension, associated with cerebrospinal fluid (CSF) fistula in this issue. In recent decades, many publications have been addressing the subject. Spontaneous intracranial hypotension is little known among physicians, and the diagnosis is difficult even considering neurologists. Many patients progress without the correct diagnosis for weeks or even months. The clinical expression is classically similar to that found in post-dural puncture headache syndrome, an entity prevalent after spinal anesthesia. The most frequent symptom presentation is orthostatic headache, which worsens in the upright position and subsides after lying down.

Bem Junior e colaboradores publicaram nesta edição um relato de caso muito interessante e oportuno sobre hipotensão intracraniana espontânea, associada à fístula do líquido cefalorraquidiano (LCR). Nas últimas décadas, muitas publicações têm abordado o assunto. A hipotensão intracraniana espontânea é pouco conhecida entre os médicos e o diagnóstico é difícil mesmo entre neurologistas. Muitos pacientes evoluem sem o diagnóstico correto por semanas ou até meses. A expressão clínica é classicamente semelhante à encontrada na síndrome da cefaleia pós-punção dural, entidade prevalente após raquianestesia. O sintoma mais frequente é a cefaleia ortostática, que piora na posição ortostática e cede após deitar.

Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center / Hipotensão intracraniana espontânea: de trombose venosa cerebral ao tratamento cirúrgico: uma série de casos de um centro terciário de saúde brasileiro

Abstract Background Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT). Objective To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward. Methods Review of the medical files of three patients and description of clinical and surgical outcomes. Results Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with lamino-plasty. Both of them had uneventful recovery and remission in surgery follow-up. Conclusion The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.

Resumo Antecedentes Hipotensão intracraniana espontânea (HIE) é uma causa secundária de cefaleia e uma doença subdiagnosticada. A apresentação clínica pode ser muito variável. Tipicamente, se apresenta com queixas isoladas de cefaleia ortostática clássica, porém pode evoluir com complicações significativas como trombose venosa cerebral (TVC). Objetivo Relatar 3 casos de diagnóstico de hipotensão intracraniana espontânea manejados em uma enfermaria de neurologia de nível terciário. Métodos Revisão dos prontuários de três pacientes e descrição dos resultados clínicos e cirúrgicos. Resultados Três pacientes do sexo feminino com média de idade de 25.6 ± 10.0 anos. As pacientes apresentavam cefaleia ortostática e uma delas apresentou sonolência e diplopia devido a TVC. A ressonância magnética (RM) do encéfalo varia de achados normais até achados clássicos de HIE como realce paquimeníngeo e deslocamento inferior das tonsilas cerebelares. A RM da coluna mostrou coleções anormais de líquido epidural em todos os casos e a mielografia por tomografia computadorizada (TC) foi capaz de determinar fístula liquórica identificável em apenas uma paciente. Uma paciente recebeu abordagem conservadora e as outras duas foram submetidas a cirurgia aberta com laminoplastia. Ambas tiveram recuperação e remissão sem intercorrências no seguimento cirúrgico. Conclusão O diagnóstico e manejo da hipotensão intracraniana ainda são desafios na prática neurológica. Destacamos no presente estudo casos graves, complicação com TVC e bons resultados com tratamento neurocirúrgico.

Spontaneous intracranial hypotension associated with posterior reversible encephalopathy syndrome

Spontaneous intracranial hypotension (SIH) is usually due to cerebrospinal fluid (CSF) leak, resulting in loss of CSF volume. Posterior reversible encephalopathy syndrome (PRES) is the inability of the posterior circulation of the brain to autoregulate in response to significant variation in blood pressure.Altered perfusion with associated blood-brain barrier disruption may lead to vasogenic edema, usually without infarction, commonly in the parieto-occipital regions. Magnetic resonance (MR) imaging of the brain and spine and cerebral MR venography are essential tools for diagnosing clinically suspected SIH and PRES. We present 18-year-young gentleman with clinical and radiological signs of SIH, which later evolved toward PRES.

Trombose de seio sigmoide secundária a fístula liquórica espontânea para osso temporal: um relato de caso / Sigmoid sinus thrombosis secondary to spontaneous temporal bone cerebrospinal fluid fistula: a case report

A fístula liquórica para o osso temporal constitui um evento raro que decorre da comunicação anormal entre o espaço subaracnóideo e as células da mastoide, permitindo que o líquido cefalorraquidiano flua para as porções pneumatizadas do osso temporal. Tem como consequência a hipotensão intracraniana espontânea, caracterizada por perda de líquor e pela manifestação clínica de cefaleia ortostática. Acredita-se que a hipotensão intracraniana espontânea crie condições hemodinâmicas favoráveis à ocorrência de trombose venosa cerebral, uma desordem potencialmente fatal e de difícil diagnóstico, visto a inespecificidade de sinais clínicos e sintomas. Dessa forma, é pertinente atentar para a possibilidade de trombose venosa cerebral em pacientes com fístulas liquóricas, especialmente quando houver mudança do padrão da cefaleia, que passa de ortostática a intensa e contínua.

Temporal bone cerebrospinal fluid fistula is a rare event that results from abnormal communication between the subarachnoid space and the mastoid cells, allowing the cerebrospinal fluid to flow into the pneumatized portions of the temporal bone. It leads to spontaneous intracranial hypotension, characterized by loss of cerebrospinal fluid and orthostatic headache as a clinical manifestation. Spontaneous intracranial hypotension is believed to create favorable hemodynamic conditions to the occurrence of cerebral venous thrombosis, a potentially fatal disorder of difficult diagnosis given the nonspecific clinical signs and symptoms. Therefore, it is pertinent to consider the possibility of cerebral venous thrombosis in patients with cerebrospinal fluid fistulas, especially when there is a modification in the headache pattern from orthostatic to intense and continuous pain.

Coma in spontaneous intracranial hypotension complicated with subdural hematoma: a case report / 中华神经科杂志

Spontaneous intracranial hypotension can frequently result in several complications including subdural hygroma, subdural hematoma and cerebral venous thrombosis, but coma rarely. A case of spontaneous intracranial hypotension presented with orthostatic headaches was described. He experienced somnolence, disorientation, incontinence, and then coma, though received conservative treatment. Brain imaging demonstrated acute-on-chronic subdural hematoma, magnetic resonance myelography using heavily T 2-weighted fast spin-echo pulse sequences showed spinal longitudinal extradural collection, and magnetic resonance myelography with intrathecal gadolinium revealed cerebrospinal fluid leak at the level of T 6, T 7. The patient recovered consciousness after surgical evacuation of the hematoma, and the headache disappeared after a targeted epidural blood patch. The hematoma resolved 2 months later and the patient kept free from headache during follow-up.

Ectasia dural e hipotensión endocraneal en síndrome de Marfán / Dural ectasia and intracranial hypotension in Marfan syndrome

INTRODUCCIÓN: El síndrome de Marfán es un trastorno multisistémico del tejido conectivo de herencia autosómica dominante, de expresión variable. La ectasia dural es un compromiso frecuente, pero poco conocido, que puede asociarse a síndrome de hipotensión endocraneana (SHE). OBJETIVO: Pre sentar un caso de cefalea invalidante secundario a SHE, para advertir de esta rara complicación, que debe tenerse presente en niños portadores de conectivopatías, en especial síndrome de Marfán. CASO CLÍNICO: Adolescente femenina de 13 años, portadora de sindrome de Marfán, de diagnóstico clínico según criterios de Ghent 2010, que consultó por cefalea ortostatica invalidante de 6 meses de evolución. La Resonancia Magnetica (RM) de cerebro mostró múltiples signos de hipotensión endocraneana, mientras que la RM de columna total mostró una ectasia dural que determinó la dilatación del saco tecal y remodelación posterior de los cuerpos vertebrales, especialmente a nivel del sacro. Se realizó tratamiento con parche sanguíneo autólogo epidural con buena respuesta clínica. CONCLUSIONES: La ectasia dural, frecuente en el sindrome de Marfán, es una causa predisponente a fuga de líquido cefaloraquideo (LCR), que podría causar cefalea ortostática segundaria al SHE.

INTRODUCTION: Marfan syndrome is an autosomal dominant, multi-systemic connective tissue di sorder of different presentations. Dural ectasia is a common, but little known complication that can be associated with intracranial hypotension syndrome (IHS). OBJECTIVE: To present a case of severe headache secondary to IHS in order to warn about this rare complication, which must be considered in children carriers of connective tissue diseases, especially Marfan syndrome. CLINICAL CASE: 13-year- old female carrier of Marfan syndrome, clinically diagnosed according to the 2010 Ghent criteria, who consulted due to a 6-months history of severe orthostatic headache. Head magnetic resonance imaging (MRI) showed multiple signs of intracranial hypotension, while whole-spine MRI showed dural ectasia that caused the thecal sac dilation and subsequent remodeling of vertebral bodies, es pecially the sacral ones. Treatment with an autologous epidural blood patch was administered with good clinical response. CONCLUSIONS: Dural ectasia, frequent in Marfan syndrome, is a predisposing cause of cerebrospinal fluid (CSF) leakage, which could cause orthostatic headache secondary to IHS.

Clinical efficacy of CT-guided epidural autogenous blood patch in treatment of spontaneous refractory intracranial hypotension headache / 中国介入影像与治疗学

Objective: To observe the efficacy and safety of CT-guided epidural blood patch (EBP) in treatment of spontaneous refractory intracranial hypotension headache. Methods: Clinical and imaging data of 12 patients with spontaneous intracranial hypotension headache treated with CT-guided EBP were retrospectively analyzed, and visual analogue scale (VAS) and complications were calculated before and after procedures. Results: A total of 12 patients received 19 CT-guided EBP therapy, among which 7 patients received secondary EBP therapy. Five patients had postoperatively localized neck pain unrelated to body position, and then healed spontaneously within 1 week. No serious complication occurred. VAS of all patients at each time point after operation was lower than that before operation (all P<0.01), and the clinical symptoms relieved or disappeared after operation. No recurrence was detected during 3 months' follow-up. Conclusion: CT-guided EBP is effective and safe in treatment of spontaneous refractory intracranial hypotension headache.

Low cerebrospinal fluid pressure may not be necessary in the diagnosis of spontaneous intracranial hypotension: A report of four cases

@#We presented four patients with sub-acute onset orthostatic headache in occipital and sub-occipital regions and neck pain. No loss of consciousness, neurologic deficit, trauma or cranial/spinal surgery history was noted. They had normal cerebrospinal fluid (CSF) opening pressure, normal laboratory studies, and diffuse pachymeningeal enhancement or sagging of brain on gadolinium-enhanced magnetic resonance imaging (MRI). Their symptoms resolved with intravenous large isotonic fluid or epidural blood patch. The diagnosis of spontaneous intracranial hypotension requires history of orthostatic headache, demonstration of lower CSF pressure, and abnormal findings on MRI. But these patients may have normal CSF opening pressure. CSF hypovolemia rather than CSF hypotension has been proposed as the underlying cause. Therefore, the CSF pressure may not be necessary for diagnosis in such patients with typical radiographic features. Thus, in the presence of convincing clinical symptoms and imaging abnormalities, a normal CSF pressure should not discourage the clinician from searching for a source of CSF leak.

Intracranial Subdural Hematoma after Lumbar Spine Surgery: A Case Report

@#Intracranial subdural hematoma following lumbar surgery is a devastating but rare complication. It has been implicated due to intracranial hypotension secondary to persistent cerebrospinal fluid leakage. The resultant drop in intracranial pressure presumably causes traction and tearing of venous structures. Patients typically present with postural headaches. However, other symptoms of subdural hematoma, intracranial hypotension and cerebrospinal fluid leak must also be cautioned.

Neurological Symptoms of Intracranial Hypotension

Intracranial hypotension usually arises in the context of known or suspected leak of cerebrospinal fluid (CSF). This leakage leads to a fall in intracranial CSF pressure and CSF volume. The most common clinical manifestation of intracranial hypotension is orthostatic headache. Post-dural puncture headache and CSF fistula headache are classified along with headache attributed to spontaneous intracranial hypotension as headache attributed to low CSF pressure by the International Classification of Headache Disorders. Headache attributed to low CSF pressure is usually but not always orthostatic. The orthostatic features at its onset can become less prominent over time. Other manifestations of intracranial hypotension are nausea, spine pain, neck stiffness, photophobia, hearing abnormalities, tinnitus, dizziness, gait unsteadiness, cognitive and mental status changes, movement disorders and upper extremity radicular symptoms. There are two presumed pathophysiologic mechanisms behind the development of various manifestations of intracranial hypotension. Firstly, CSF loss leads to downward shift of the brain causing traction on the anchoring and supporting structures of the brain. Secondly, CSF loss results in compensatory meningeal venodilation. Headaches presenting acutely after an intervention or trauma that is known to cause CSF leakage are easy to diagnose. However, a high degree of suspicion is required to make the diagnosis of spontaneous intracranial hypotension and understanding various neurological symptoms of intracranial hypotension may help clinicians.

Spontaneous Intracranial Hypotension Complicated by Cerebral Venous Thrombosis Relieved by Epidural Blood Patch

Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, diffuse dural thickening, and enhancement in magnetic resonance imaging. Cerebral venous thrombosis (CVT) has been reported to be a rare complication of SIH. There is no consensus in anticoagulation treatment of CVT secondarily caused by SIH. We report a female patient with SIH complicated by CVT and spontaneously regressed CVT not by anticoagulation but by epidural blood patch.

Multiple epidural fibrin glue patches in a patient with spontaneous intracranial hypotension:A case report

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a condition caused by spontaneous leakage of cerebrospinal fluid, with postural headache as the primary symptom. Orthostatic headache caused by SIH is often not resolved by conservative management. CASE: We performed 15 epidural blood patch treatments in a 43-year-old female patient; however, they were only transiently effective. To improve the patient's SIH and orthostatic headache, epidural fibrin glue patch treatment was attempted. Fibrin glue is a substance that can act as a bio-friendly adhesive by facilitating the coagulation cascade. In our case, 3 epidural fibrin glue patch treatments were performed and the symptoms completely resolved. CONCLUSIONS: The epidural fibrin glue patch may be beneficial for the treatment of refractory postural headaches caused by SIH.

Susceptibility-Weighted MR Imaging for the Detection of Isolated Cortical Vein Thrombosis in a Patient with Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) can be a rare risk factor of cerebral venous thrombosis. We describe a case of isolated cortical vein thrombosis (CVT) secondary to SIH and discuss the value of susceptibility-weighted imaging for the detection of isolated CVT.

Application of myelography in diagnosis and therapy of spontaneous intracranial hypotension / 中华神经科杂志

Objective To investigate the application of myelography including digital subtraction angiography myelogram (DSM) and computed tomography myelogram (CTM) in patients with spontaneous intracranial hypotension.Methods The myelography results including DSM and CTM of 10 patients with spontaneous intracranial hypotension form Guangzhou First People's Hospital between January 2013 and June 2018 were retrospectively analyzed.Some patients were treated with targeted epidural blood patch on the basis of myelography.Results Myelography (including DSM and CTM) showed cerebrospinal fluid leakages in all the 10 patients.There were one to 16 leak sites with an average of nine sites (totally 90 leak sites).Forty-two sites (47％) were located in cervical vertebra,19 sites (21％) in thoracic vertebra,22 sites (24％) in lumbar vertebra,and seven sites (8％) in sacral vertebra.On DSM and CTM,cerebrospinal fluid leakage was characterized by the diffusion of contrast agent along one side or the bilateral sides of nerve root,enlargement of the nerve sleeves and paraspinal collections of hyper-demity contrast medium.Two patients whose cerebrospinal fluid leakage occurred in long sections showed more cerebrospinal fluid leakage on CTM than on DSM.Two patients responded well to targeted epidural blood patch on the basis of myelography.The cerebrospinal fluid leakage was completely settled on myelography after the treatment of epidural blood patches.Conclusions Myelography has been shown to assist the diagnosis of spontaneous intracranial hypotension and accurately define the location and extent of cerebrospinal fluid leakages.Myelography can be used to guide targeted epidural blood patch and applied in the reexamination of cerebrospinal fluid leakages after treatment.More cerebrospinal fluid leakages are detected by CTM than by DSM.

Rebound intracranial hypertension after noninvasive treatment of intracranial hypotension: Case report and literature review

@#Intracranial hypotension is a clinical syndrome characterized by orthostatic headache and low cerebrospinal fluid pressure. Noninvasive management is the usual first line treatment. Epidural blood patch is the treatment of choice if noninvasive treatments are ineffective. Cases with rebound intracranial hypertension after epidural blood patch treatment have been reported in the medical literature previously. We report here three patients with rebound intracranial hypertension who were treated noninvasively for intracranial hypotension. This phenomenon has not been reported previously. The underlying cause of intracranial hypotension was epidural anesthesia in the first, lumbar disc surgery in the second patient, and idiopathic in the third patient. They had been treated either with bed rest or with medical treatment not requiring epidural blood patch. After a short remission the patients were seen with a different headache pattern. They all had papilledema on examination. Automated perimetry revealed bilateral blind spot enlargement in Patient 1 and peripheral constriction in Patient 2. Cranial MRI and MRV in all three patients were normal. All the patients recovered very quickly with acetazolamide 1.5 or 2gm/day. In conclusion, rebound intracranial hypertension should be kept in mind in patients with intracranial hypotension who developed changes in the headache pattern, had new symptoms of nausea, vomiting, blurred or double vision during follow-up. Rebound intracranial hypertension can develop after conservative treatment of intracranial hypotension.