Cerebrospinal fluid neurohypophysial peptides in benign intracranial hypertension.

The cerebrospinal fluid (CSF) concentrations of arginine vasopressin (AVP) and oxytocin (OT) were investigated both in patients with benign intracranial hypertension and in age and sex matched controls. Twenty eight lumbar punctures were performed on 15 patients with benign intracranial hypertension as part of their routine investigation and therapy. All patients had raised intracranial pressure (27.4, SE 1.7 cm.CSF). CSF AVP levels were significantly elevated in benign intracranial hypertension (2.1, SE 0.3 pmol/l) compared with controls (0.7, SE 0.1 pmol/l, p less than 0.001) but CSF OT concentrations were similar in both groups. CSF osmolality and plasma AVP and osmolality were identical in patients and controls. There was no correlation between CSF AVP concentration and intracranial pressure. The selective elevation of AVP in CSF may be of importance in the pathogenesis of raised intracranial pressure in benign intracranial hypertension.     

Computed tomographic evidence of cerebral swelling in benign intracranial hypertension.

Computed tomography of 30 patients presenting acutely with benign intracranial hypertension was compared with that of 30 normal controls matched for age and sex. Qualitative and quantitative assessments showed smaller cranial CSF spaces in the cases of benign intracranial hypertension, suggesting that cerebral swelling is involved in the pathogenesis of benign intracranial hypertension.     

Spontaneous intracranial hypotension in the absence of magnetic resonance imaging abnormalities

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a neurologic syndrome of unknown etiology, characterized by features of low cerebral spinal fluid (CSF) pressure, postural headache and magnetic resonance imaging (MRI) abnormalities. METHODS: Four symptomatic cases of SIH presented to our institution over a six-month period. Magnetic resonance imaging studies were performed in all four cases. Diagnostic lumbar puncture was done in all except one case. RESULTS: All of the patients on whom lumbar punctures were performed demonstrated low CSF pressure and CSF protein elevation with negative cultures and cytology. Three out of the four patients exhibited MRI findings of diffuse spinal and intracranial pachymeningeal gadolinium enhancement and extradural or subdural fluid collections. One patient had no MRI abnormalities despite prominent postural headache and reduced CSF pressure at lumbar puncture. All patients recovered with intravenous fluids and conservative treatment. CONCLUSIONS: Magnetic resonance imaging abnormalities are found in most, but not all patients, with SIH. Cerebral spinal fluid abnormalities can be detected even in patients with normal MRI studies. It is important to recognize the variability of imaging results in this usually benign disorder.     

Shunt failure in idiopathic intracranial hypertension presenting with spontaneous cerebrospinal fluid leak.

A case of spontaneous cerebrospinal (CSF) fluid leak after ventriculoperitoneal shunt (VPS) failure in a patient with idiopathic intracranial hypertension (IIH) is reported. This is the first report of spontaneous CSF leak in an IIH patient without a history of trauma, sinus surgery, or intracranial surgery. The diagnosis was confirmed using thin-sliced post-contrast computed tomography, which revealed a micro-dehiscence of the cribiform plate at the superior aspect of the ethmoid sinus. The patient underwent VPS revision without complication, resulting in complete amelioration of symptoms and cessation of CSF rhinorrhoea at 1 year follow up.     

EEG in benign intracranial hypertension

A retrospective study of standard EEG's obtained from 26 patients with benign intracranial hypertension was done with particular emphasis on the effect of age on the EEG findings. Abnormal EEG's were found in 10 patients, all were less than 20 years of age. Although no consistent pattern of EEG abnormality could be identified, there appears to be a difference between the immature and adult brain in the EEG response to intracranial hypertension.     

The effect of optic nerve sheath decompression on CSF dynamics in pseudotumour cerebri and related conditions

The effect of optic nerve sheath decompression (ONSD) on cerebrospinal fluid (CSF) pressure and outflow resistance was studied in six patients who underwent the procedure (four unilateral, two bilateral) for papilloedema secondary to raised intracranial pressure. Four patients (all female, average age 29.3 years) had pseudotumour cerebri while two patients (one male 34 years, one female 24 years) had cryptococcal meningitis. All patients had pre- and postoperative CSF pressure measurements. Three patients had a preoperative CSF infusion study and all six had a postoperative study to measure CSF outflow resistance. Five of the six patients had elevated CSF pressure prior to ONSD and in all five the pressure was still significantly elevated after the procedure. In one symptomatic patient with papilloedema the pressure was normal pre- and post-ONSD (this patient was on acetazolamide). All three patients who tested pre-ONSD had an abnormal outflow resistance; in only one case did this become normal after the procedure, although this patient later required shunting for persistent intracranial hypertension. Clinically, only one of the six cases had a substantial relief of symptoms and signs despite persistently high CSF pressure and outflow resistance. The other five patients went on to shunting after intervals ranging from one week to 8 months. The preliminary conclusion was drawn that ONSD does not have any predictable beneficial effect on CSF pressure or outflow resistance.     

Cerebrospinal fluid vasopressin in neurological and psychiatric disorders.

Vasopressin was determined in CSF and plasma of 243 patients with different neurological and psychiatric disorders, including control patients. CSF vasopressin was significantly higher in patients with high pressure hydrocephalus, intracranial tumour, benign intracranial hypertension, intracranial haemorrhage, ischaemic stroke, and craniocerebral trauma. In patients with primary degenerative dementia, CSF vasopressin was lower than in control patients. Among patients with psychiatric disorders, CSF vasopressin was increased in manic patients, while in patients with depression CSF concentration of this hormone did not differ from that found in controls. However, an increase in CSF vasopressin level was found in patients recovering from a depression. The clinical significance of changes in CSF vasopressin concentrations in groups of patients with neurological and psychiatric disorders is still unknown.     

An unusual case of superior sagittal sinus thrombosis accompanied with dural AV fistula]

Benign intracranial hypertension or pseudotumor cerebri is an collective term for a number of diverse syndromes characterized by increased intracranial pressure. Neither intracranial mass nor ventricular dilatation is observed in this disorder. Moreover, the pathogenesis of this syndrome has yet to be determined. We report a case of 36-year-old female diagnosed as benign intracranial hypertension, who has developed superior sagittal sinus thrombosis and dural AV fistula during the follow up period. The patient was pointed out to have papilledema and elevated intracranial pressure six years ago. Although she was examined by both DSA and CT scan, no abnormal intracranial lesions were observed. Consequently, she was diagnosed as the benign intracranial hypertension and had been followed as an out patient. Three years later, lumboperitoneal shunting was performed because of severe headache and visual impairment. Postoperatively, the patient had been well for two years. Recently, occipital headache recurred and she was readmitted to our hospital. MRI studies demonstrated dilated vessels in the right occipital area. Additionally, angiograms revealed not only the superior sagittal sinus thrombosis but also the rich network of dural AV fistula adjacent to the occlusion. According to those results, the superior sagittal sinus was supposed to have the incomplete occlusion or delayed blood flow that were not observed by DSA, MRI and CT scan performed previously. Those occlusive change in the superior sagittal sinus impeded the CSF absorption and elevated the pressure of venous inflow, then the arterio-venous communication has been developed.(ABSTRACT TRUNCATED AT 250 WORDS)     

外伤性颅底骨折所致脑脊液漏的处理及预后因素分析

目的分析影响外伤性颅底骨折所致脑脊液漏愈合的相关因素,以探索外伤性脑脊液漏更好的治疗策略。方法回顾性分析2000年2月至2009年4月期间收治的外伤后颅底骨折所致的脑脊液漏患者的临床资料,收集患者基本信息,入院时GCS评分,脑脊液漏的类型(鼻漏、耳漏)、治疗方式(保守治疗、腰大池引流、手术),有无颅内感染、脑脊液漏预后状况等相关临床资料,采用SPSS软件统计分析可能影响脑脊液漏愈合的相关因素。结果 83例脑脊液漏患者中,男性患者55名,女性患者28名,年龄16~73岁,平均43.8±17.3岁。其中11例患者因颅内合并伤(颅内血肿、神经损伤等)、广泛性颅底骨折、严重的脑脊液漏等行急诊手术治疗,39例患者采用保守治疗脑脊液漏愈合,31例采用腰大池置管引流愈合,2例经保守观察及腰大池引流治疗后仍未治愈行开颅手术修补后愈合。治疗效果满意,无死亡病例,仅1例颅内感染病例。影响脑脊液漏愈合相关因素包括:患者年龄、入院时GCS评分、脑脊液漏的类型。结论多数外伤性脑脊液漏经保守治疗或腰大池置管引流治疗后可愈合,因合并伤需要手术、颅骨广泛性骨折、脑脊液漏严重者需尽早手术治疗。     

Regional cerebral oxygen utilization, blood flow, and blood volume in benign intracranial hypertension studied by positron emission tomography

Using PET, we measured regional cerebral oxygen utilization, oxygen extraction, blood flow, and blood volume in five patients with benign intracranial hypertension. No significant differences in regional cerebral function were found between the patients and 15 age-matched normal controls. Cerebral decompression with a lumboperitoneal shunt produced little change in regional cerebral function in one patient studied serially. The raised CSF pressure of benign intracranial hypertension is therefore not associated with any significant deterioration in cerebral oxygen metabolism or hemodynamics.     

Benign intracranial hypertension: A retrospective and follow-up study

Thirty-six patients with benign intracranial hypertension (BIH) were reviewed. Follow-up was obtained on 33 patients (91%) after a mean period of $\text{7}\text{1}\text{2}$ years. Precipitating factors were found in 27 patients (75%). On admission, 5 patients had retro-ocular pain, especially on eye movements, a complaint not yet described in BIH. Seven patients had nystagmus, two of them horizontal positional nystagmus. It is questionable whether all signs in BIH are caused by the raised CSF pressure.The general outcome was good. Only two patients sustained severe ultimate visual impairment. Both presented with retro-ocular pain and sudden loss of vision on admission. Papilloedema can persist for years in BIH without serious visual impairment. Sometimes “causal” treatment is possible. No symptomatic treatment which is free from complications has been proved to prevent visual failure.     

Intraoperative values of S-100 protein, myelin basic protein, lactate, and albumin in the CSF and serum of neurosurgical patients

OBJECTIVES: To assess the concentrations of S-100 protein, myelin basic protein (MBP), and lactate, and the (CSF)/serum albumin ratio (Qalb) during intracranial neurosurgical procedures. METHODS: Samples of CSF from 91 patients with various CNS diseases were obtained by aspiration of cisternal CSF at the beginning of surgery (before starting surgical manipulation of the brain) and concentrations of S-100 protein, MBP, and lactate, and Qalb were determined. At the same time blood was sampled for determination of serum S-100 protein concentration. Patients were divided into three groups according to the aetiology of their CNS disease (intracranial haemorrhage, n=11; benign intracranial mass lesion, n=52; malignant neoplastic disease, n=28). Radiological and intraoperative characteristics were documented. RESULTS: In each of these three groups median values of all four CSF variables measured were raised. The occurrence of brain oedema and a midline shift correlated significantly with raised concentrations of MBP and Qalb. Breaching of the arachnoid layer, documented at surgery for benign lesions, correlated with higher concentrations of MBP, lactate, CSF S-100 protein, and Qalb. CONCLUSIONS: Intraoperative values of S-100 protein, MBP, lactate, and Qalb are increased in patients with intracranial haemorrhage, benign intracranial mass lesion, and malignant neoplastic disease. Breaching of the arachnoid layer and oedema is associated with higher concentrations of some of the aforementioned proteins. These biochemical data can serve as a basis for further research into CSF specific proteins.     

Intracranial pressure in patients with the empty sella syndrome without benign intracranial hypertension.

The intracranial pressure was monitored continuously for at least 48 hours in five patients with empty sella syndrome, who did not have clinical benign intracranial hypertension (BIH). It has been suggested that the empty sella syndrome is a result of chronically elevated intracranial pressure in the presence of a congenitally deficient diaphragma sellae. However, whilst the intracranial pressure in two of the five patients was abnormally high, in three patients in whom it was monitored, the CSF pressure was normal. Although these cases may represent "burnt out" forms of intracranial pressure problems, it might be that the normal pulsations of CSF are sufficient to produce the empty sella in the presence of a deficient diaphragma sella.     

Indomethacin reduces CSF pressure in intracranial hypertension

The CSF-pressure-lowering effects of indomethacin in seven patients with idiopathic intracranial hypertension and one patient with symptomatic intracranial hypertension due to a non-space-occupying meningioma are reported. CSF opening pressure between 350 and 500 mm H2O (mean 400 mm H2O) was promptly reduced by 80 to 200 mm H2O (mean reduction, 139 mm H2O) for at least 10 minutes in all patients after IV administration of 50 mg indomethacin. Four patients had mild and transient side effects (dizziness). Indomethacin might be an alternative drug for treatment of intracranial hypertension.     

Is "benign intracranial hypertension" really benign?

Hypothalamic-hypophyseal insufficiency has been found in seven of eight patients with so-called benign intracranial hypertension, of whom four showed an inadequate adrenal response to stress. The syndrome of benign intracranial hypertension cannot therefore be considered entirely benign and patients should receive full endocrinological assessment and follow up.     

Digital subtraction cisternography: a new approach to fistula localisation in cerebrospinal fluid rhinorrhoea.

Positive contrast cisternography with digital subtraction of fluoroscopy images before computed tomography (CT) was employed in the investigation of eight patients with cerebrospinal fluid (CSF) rhinorrhoea. Fistulae were visualised by preliminary digital subtraction cisternography (DSC) in six patients and in five patients the sites of leakage were confirmed at surgery. Fluoroscopy facilitated interpretation of CT in all the positive studies and in two patients provided information which could not be deduced from CT cisternography (CTC) alone. The combined technique is recommended for the investigation of patients with recurrent and post operative CSF rhinorrhoea and when CTC alone fails to identify the site of leakage.     

Idiopathic "benign" intracranial hypertension: case series and review.

Idiopathic "benign" intracranial hypertension is an uncommon but important cause of headache that can lead to visual loss. This study was undertaken to review our experience in the diagnosis and management of idiopathic intracranial hypertension, giving special attention to treatments used. A retrospective chart review was conducted on 32 patients diagnosed with idiopathic intracranial hypertension between 1984 and 1995. Subjects included 23 females and ranged in age from 2 to 17.5 years. Headache was the most common symptom, followed by nausea and vomiting, double vision, and visual loss. Papilledema was the most common sign. Others were VIth cranial nerve palsy and compromised visual acuity at or within 3 months of presentation. Management included administration of acetazolamide or corticosteroids, lumboperitoneal shunt, optic nerve fenestration, and repeat lumbar puncture. Treatment combinations were used in 40% of cases. During follow-up, headache, papilledema, and decreased visual acuity persisted for longer than 10 months in a significant number of patients. We conclude that idiopathic intracranial hypertension causes significant short- and long-term morbidity with no proven effective treatment available. A prospective study is needed to establish the indications for treatment and the efficacy of the treatments used.     

Mean intracranial pressure monitoring by a non-invasive audiological technique: a pilot study.

Intracranial pressure is normally transmitted to the perilymph of the cochlea via the cochlear aqueduct. The relationship between perilymphatic pressure, indirectly measured by tympanic membrane displacement, and mean intracranial pressure defined either clinically or by direct measurement has been examined in 58 patients (aged 5-77 years), with hydrocephalus, benign intracranial hypertension, intracranial tumours, subarachnoid haemorrhage and head injuries. The most consistent results were obtained in young patients with hydrocephalus and benign intracranial hypertension. However, the technique was not suitable when the stapedial reflex was absent as a result of middle ear/brainstem dysfunction and did not reflect intracranial pressure when the cochlear aqueduct was not patent. This pilot study suggests that the tympanic membrane displacement technique may provide a useful non-invasive method for serial monitoring of intracranial pressure in young patients with hydrocephalus or benign intracranial hypertension.     

Bilateral papilledema: prospective study of fifty patients

In this prospective study, we report fifty consecutive cases of bilateral papilledema without neurosurgical or obvious ophthalmologic etiology, referred to our institution between January 2005 and March 2007. Lumbar puncture with opening CSF pressure measurement distinguished two groups of patients: Group 1 (n=39) with and Group 2 (n=11) without intracranial hypertension. In Group 1, 9/39 patients presented secondary intracranial hypertension mainly due to cerebral venous thrombosis. In 30 patients, after complete investigations, a diagnosis of idiopathic intracranial hypertension was made: as commonly reported, patients were predominantly overweight (96.7% with body mass index>25kg/m2) young (mean age=27.6 years) and women (96.7%). Eleven patients with intracranial hypertension had no headaches. In Group 2, the most common diagnosis was bilateral non-arteritic anterior ischemic optic neuropathy, but rare causes have been identified.