Overview of Spontaneous Intracranial Hypotension and Differential Diagnosis with Chiari I Malformation.

Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.

Embolic Stroke of Undetermined Source: Role of Implantable Loop Recorder in Secondary Prevention.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most important cause of embolic stroke of undetermined source (ESUS). Implantable loop recorder (ILR) demonstrated the highest sensitivity for detecting it. This register was created to confirm the high prevalence of AF in patients after ESUS and to verify possible benefits on clinical outcomes such as TIA (Transient Ischaemic Attack)/stroke recurrence and death using ILR. METHODS: A total of 278 patients admitted to "Molinette" Hospital in Stroke Unit department between 2011 and 2016, diagnosed with ESUS, underwent ILR implantation if they had at least one risk factor for AF. A total of 165 patients admitted to other departments in the same center for the same pathology, without ILR, represent the control group. We used propensity score to select 132 patients from each group (matching age, sex, CHADS-VASC, and HAS-BLEED baseline characteristics). RESULTS: The detection rate of AF episodes was significantly higher in the ILR group (p < 0.001). No significant protective role of ILR for clinical endpoints was found on univariate analysis, although a trend towards significance has been pointed for the composite outcome of death and ischemic events recurrence (OR 0.52, CI 0.26-1.04, p = 0.06). A protective role of ILR was found for deaths (OR 0.4, CI 0.17-0.94, p 0.03) and for the composite outcome (OR 0.41, CI 0.19-0.87, p 0.02) on multivariate analysis in the best subsets. CONCLUSION: With our statistical models, we identified a significant clinical benefit from ILR monitoring, evidenced by a trend of less death and TIA/stroke recurrence and relevant ILR protection for prediction of TIA/stroke recurrence.

CSF-venous leak responsible for spontaneous intracranial hypotension treated by endovascular venous route: First cases in Italy.

Spontaneous intracranial hypotension (SIH) is due to a leakage of CSF lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. Clinical and MRI are usually typical enough to allow diagnosis, while finding the location of the dural breach is challenging. Since some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic path has been proposed. Here we report the first two successfully treated patients in Italy. Both had chronic and non specific symptoms, with severe reduction of quality of life; clinical symptoms improved after endovascular occlusion of the responsible vein.

Trans-oral approach for occipital condyle biopsy: Case report and review of literature.

Isolated occipital condyle lesions are commonly treated with empirical radiation, with the sole aim of relieving symptoms. Patients rarely undergo surgical biopsy, considering the morbidity associated with open surgery approaches and the importance of surrounding structures limiting the application of computed tomography (CT) scan or fluoroscopic percutaneous needle biopsies. We describe the case of a 66-year-old woman who was admitted on an emergency basis. Her clinical presentation included unilateral occipital headache and ipsilateral hypoglossal nerve palsy. Imaging revealed findings consistent with an isolated right occipital condyle lesion. In order to pursue a tissue diagnosis, essential to dictate medical management accurately, a minimally invasive biopsy of the occipital condyle through the trans-oral route was performed. Combined fluoroscopy, cone-bean CT and angiography allowed safe access to the lesion.