A New Mechanism of Cerebrospinal Fluid Leakage after Lumboperitoneal Shunt: A Theory of Shunt Side Hole—Case Report

Cerebrospinal fluid (CSF) overdrainage after lumboperitoneal (LP) shunt placement for the patients with idiopathic normal pressure hydrocephalus (iNPH) is mainly caused by insufficient management of pressure settings of the shunt valve and/or siphon effect of shunt systems induced by the patient''s postural changes. We here report a unique case of intracranial hypotension (IH) due to CSF leakage after LP shunt placement in which another mechanism leads to the CSF leakage. A 67-year-old man suffered from persistent headache worsening with postural change 2 months after LP shunt reconstruction for iNPH. Brain computed tomography scan showed bilateral chronic subdural hematomas (CSDH). Lumbar images including shuntography and magnetic resonance imaging showed the tip of the lumbar catheter was spontaneously pulled out close to the dura mater with expansion of the epidural space due to CSF leakage from a shunt side hole of the lumbar catheter to the epidural space. Shunt removal and subsequent irrigation of CSDH improved his headache. CSF leakage in our case differs from those in previous reports, because early and enormous CSF leakage into the epidural space can be explained only by a different mechanism through a side hole just located in the epidural space in our case. We must pay attention to the possibility of this rare cause of IH due to CSF leakage in patients suffering from postural headache after LP shunt placement.     

Epidural blood patch for the treatment of intracranial hypotension due to cerebrospinal fluid leakage after thoracic spine surgery

We report a case of a 44-year-old woman successfully treated by an epidural blood patch for intracranial hypotension due to cerebrospinal fluid (CSF) leakage into the thoracic cavity after thoracic spine surgery. The patient was admitted to our hospital with the complaint of postural headaches. She had received anterior thoracic instrumentation for thoracic disc herniation four months earlier. Lumbar puncture demonstrated low CSF pressure, and Gd-enhanced MR images displayed diffuse dural enhancement. Accordingly, she was diagnosed as having intracranial hypotension. 111In-DTPA cisternography revealed a CSF leakage into the left thoracic cavity, possibly caused by dural laceration during thoracic spine surgery. To avoid the risk of direct surgery, we performed epidural blood patch; 3 ml of autologous blood was injected into the epidural cavity. Postoperatively postural headaches immediately disappeared. MRI taken one year later revealed disappearance of diffuse dural enhancement, and 111In-DTPA cisternography revealed no CSF fluid leaks. Epidural blood patch seems to be a choice of treatment for CSF leak after spinal surgery.     

Epidural blood patch for headache after lumboperitoneal shunt placement

Headaches complicating lumboperitoneal (LP) shunt placement have been attributed to shunt failure with resultant high intracranial pressure or to overdrainage with resultant low intracranial pressure. In this case, a 17-yr-old girl had symptoms of a low-pressure headache after LP shunt placement alleviated by an epidural blood patch. The success of this therapy suggests postdural puncture as a possible cause for low-pressure headache after LP shunt placement. Epidural blood patch may be an alternative initial therapy for some low-pressure headaches after LP shunt placement.     

Intracranial hypotension without meningeal enhancement on magnetic resonance imaging. Case report

Meningeal enhancement on magnetic resonance (MR) imaging is considered the hallmark radiological feature of intracranial hypotension. The authors report on a patient who exhibited progressively symptomatic intracranial hypotension due to a lumbar cerebrospinal fluid (CSF) leak, but in whom MR imaging demonstrated no pachymeningeal enhancement. This 24-year-old man presented with a 6-week history of progressive orthostatic headaches that were associated with photo- and phonophobia. Four weeks before the onset of the headaches, the patient had undergone a lumbar laminectomy. Brain MR images revealed subdural fluid collections and brain sagging; however, meningeal enhancement was not present. Myelography demonstrated a CSF leak at the site of the laminectomy. At surgery, a large dural tear was repaired. The patient recovered well from the surgery, with complete resolution of his headaches. The absence of meningeal enhancement on MR imaging does not exclude a diagnosis of symptomatic intracranial hypotension.     

Intrathecal saline infusion in the treatment of obtundation associated with spontaneous intracranial hypotension: technical case report

OBJECTIVE AND IMPORTANCE: Spontaneous intracranial hypotension is an increasingly recognized cause of postural headache. However, appropriate management of obtundation caused by intracranial hypotension is not well defined. CLINICAL PRESENTATION: A 43-year-old man presented with postural headache followed by rapid decline in mental status. Imaging findings were consistent with the diagnosis of spontaneous intracranial hypotension, with bilateral subdural hematomas, pachymeningeal enhancement, and caudal displacement of posterior fossa structures and optic chiasm. INTERVENTION: Despite treatment with lumbar epidural blood patch, worsening stupor necessitated intubation and mechanical ventilation. Contrast-enhanced magnetic resonance imaging and computed tomographic myelography of the spine failed to demonstrate the site of cerebrospinal fluid fistula. The enlarging subdural fluid collections were drained, and a ventriculostomy was performed. Postoperatively, the patient remained semicomatose. To restore intraspinal and intracranial pressures, intrathecal infusion of saline was initiated. After several hours of lumbar saline infusion, lumbar and intracranial pressures normalized, and the patient's stupor resolved rapidly. Repeat computed tomographic myelography accomplished via C1-C2 puncture demonstrated a large ventrolateral T1-T3 leak, which was treated successfully with a thoracic epidural blood patch. Follow-up magnetic resonance imaging demonstrated resolution of intracranial hypotension, and the patient was discharged in excellent condition. CONCLUSION: Spontaneous intracranial hypotension may cause a decline of mental status and require lumbar intrathecal saline infusion to arrest or reverse impending central (transtentorial) herniation. This case demonstrates the use of simultaneous monitoring of lumbar and intracranial pressures to appropriately titrate the infusion and document resolution of intracranial hypotension. Maneuvers aimed at sealing the cerebrospinal fluid fistula then can be performed in a less emergent fashion after the patient's mental status has stabilized.     

Lumbar epidural blood patch to treat a large, symptomatic postsurgical cerebrospinal fluid leak of 5 weeks duration in a 3-year-old

A 3-yr-old with B-cell lymphoma presented with a 5-wk history of 400 mL/day cerebrospinal fluid (CSF) leak, which precluded chemotherapy, after placement of an Omaya reservoir and drain. Surgical repair was unsuccessful. Symptoms included irritability, failure to eat and noncommunication. After lumbar epidural blood patch with 7 mL the symptoms resolved immediately, allowing recommencement of chemotherapy. Epidural blood patch should be considered as possible early treatment for CSF leaks. IMPLICATIONS: An epidural blood patch successfully treated a large cerebrospinal fluid leak of long duration in a 3-yr-old. Considering the distress of such a leak to the patient, staff, and parents, epidural blood patch may be considered as an early treatment option.     

Lumboperitoneal shunt for idiopathic intracranial hypertension: patients’ selection and outcome

Surgical treatment of idiopathic intracranial hypertension (IIH) includes cerebrospinal fluid (CSF) diversion procedures most commonly lumboperitoneal (LP) shunt. LP shunt addresses the cause of both headache and papilledema more directly by effecting a global reduction of intracranial pressure. Twenty-two cases were included in the study. All patients underwent clinical, imaging, and CSF manometry evaluations. All patients showed failure or noncompliance to medical treatment and necessitated placement of an LP shunt. Analysis of data was conducted and evaluation of outcome was assessed. Among 22 patients who underwent LP shunt placement for IIH, 16 (72.8%) patients had severe and fulminant opening CSF pressures with values of more than 400 mmH₂O. Among this group, 19 (86.4%) patients reported recovery of their headache and 16 (72.7%) patients showed complete resolution of papilledema. Shunt complications included two (9%) cases of shunt infection that required shunt extraction and antibiotic therapy, and six (27%) cases of shunt obstruction that required shunt revision. Manometric predictors for surgical treatment of IIH may include severe and fulminant opening CSF pressures as well as poor manometric response to repeated lumbar taps. Lumboperitoneal shunt is easy and effective for treating intractable headaches and visual impairment associated with IIH. Its usefulness can be optimized by meticulous technical placement of the shunt guided by rigorous protocols for shunt procedures.     

Treatment of cerebrospinal fluid rhinorrhea by percutaneous lumboperitoneal shunting: review of 15 cases

Fifteen patients with recalcitrant cerebrospinal fluid (CSF) fistula underwent the insertion of a lumboperitoneal shunt. The shunt consists of a two-piece Silastic tube and has been used in a population of 150 patients with communicating hydrocephalus, persistent postoperative meningocele, and benign intracranial hypertension. The spinal catheter is introduced subcutaneously and no flushing device is used. We studied three groups: 9 patients had a history of head trauma, and 7 of these had undergone one or several ineffective direct approaches to the dural leak. Four patients presented with a presumably congenital fistula. Two patients had persistent rhinorrhea due to previous intracranial procedures. Indium-111 cisternography was performed in 10 patients before lumboperitonel (LP) shunting and failed in 2 of those to document the site of leakage. Twelve patients showed cessation of rhinorrhea after LP shunting. In 4 of these, shunt-related complications responded to shunt removal with no further recurrence of rhinorrhea. Two patients underwent revision of the shunt. In 3 patients, the LP shunt failed to control the CSF leak and further intracranial procedures were indicated. The LP shunt provides an attractive and technically simple solution when direct methods of treatment have failed. Additionally, LP shunting should be considered as a primary mode of treatment in elderly patients or when impairment of CSF dynamics is documented by radionuclide cisternography and computed tomographic scanning. When an LP shunt is ineffective, shunt function should be checked by isotopic studies before additional surgery is performed.     

A case of spontaneous intracranial hypotension effectively treated with cervical epidural blood patch

We report a case of cervical spontaneous intracranial hypotension (SIH). The patient is a 46-year-old woman with hard of hearing, dizziness and postural headache. Radionuclide cisternography (RNC) demonstrated a cerebrospinal fluid (CSF) leak at the low cervical region. Resolution of headache was obtained by conservative therapies of bed rest and intravenous (i.v.) drip infusion, but the dizziness remained. We performed epidural blood patch (EBP) with 8 ml of autologous blood at the C 6-7 interspace. Her dizziness disappeared after several days of EBP. SIH is an uncommon disease caused by CSF leakage. SIH is often self-limiting, responding to bed rest and/or i.v. drip infusion. However, if the symptoms of SIH do not show a complete recovery by conservative therapies, EBP or continuous epidural infusion of saline has reportedly been used for the management of these cases. Most of the reported cases of EBP are in the thoracic and lumbar spinal regions. We have performed cervical EBP without complications, and the 6 month-follow-up MRI and RNC demonstrated that the abnormal findings had disappeared.     

Cerebrospinal fluid leak demonstrated by three-dimensional computed tomographic myelography in patients with spontaneous intracranial hypotension

BACKGROUND: Precise determination of the spinal level of a cerebrospinal fluid leak is important in the diagnosis and treatment of spontaneous intracranial hypotension. The authors report two cases of SIH in which a cerebrospinal fluid leak was demonstrated by three-dimensional computed tomographic (3D-CT) myelography. CASE DESCRIPTION: By overlaying 3D-CT images of contrast-enhanced CSF and the spine, the point of leakage was clearly depicted in the three-dimensional spinal structure, which assisted targeted epidural blood patch under the guidance of fluoroscopy. Although associated chronic subdural hematoma had to be treated by burr hole drainage, the patients' postural headaches subsided after treatment. CONCLUSION: Clear CSF images in relation to vertebral bones are obtainable with 3D-CT myelography, rendering this modality very useful for the diagnosis and treatment of spontaneous intracranial hypotension.     

Caudal epidural blood patch for treating intractable vomiting in a child after placement of a permanent intrathecal catheter

Postdural puncture cerebral spinal fluid (CSF) leak most often manifests as a postdural puncture headache (PDPH). The reported frequency in young children varies (1-4). Persistent CSF leak may also be present without PDPH. We present a case of postoperative nausea and vomiting resulting from a presumed lumbar CSF leak in a nonverbal child after surgical placement of a permanent intrathecal catheter. Treatment with an epidural blood patch (EBP) via the caudal approach resulted in complete relief of symptoms.     

Improved spinal MRI findings after epidural blood patch administration: A pediatric case

Orthostatic headache is the leading clinical manifestation of CSF leakage. Anatomic changes due to low CSF pressure can be detected by cranial and spinal magnetic resonance imaging (MRI). We report improved spinal MRI findings in a pediatric case of post-dural puncture headache treated by epidural blood patch administration.In this case, a 7-year-old girl with a history of recurrent lumbar punctures and orthostatic headache for three months is presented. Cerebrospinal fluid (CSF) leak was reported at the level of T5-L1 by magnetic resonance imaging (MRI). An autologous epidural blood patch was performed under sedation with a blood volume of 6?ml. Five days after the procedure MRI showed no CSF signal in the extradural space and dural infolding was found to be disappeared. On the seventh day of the procedure, headache recurred and the procedure was repeated using same amount of blood. After seven months of follow-up, the patient reported no recurrence of headache.To the best of our knowledge, this is the first pediatric case report that presents improved spinal MRI findings following an epidural blood patch. Although MR findings show improvement, it is not a definitive proof of the adequacy of the treatment.     

Therapeutic intervention for iatrogenic thoracolumbar pseudomeningocele using ultrasound-guided aspiration and ultrasound-assisted epidural blood patch – A case report

Cerebrospinal fluid (CSF) leakage causing a pseudomeningocele is a well-recognized complication after spine surgery. It presents as a recurrence of low-back pain, radiculopathy, subcutaneous swelling, symptoms of intracranial hypotension, and delayed myelopathy. Definitive surgical repair is needed if not resolved spontaneously or with minimally invasive measures like lumbar subarachnoid drainage and an epidural blood patch (EBP). We report a case of iatrogenic thoracic pseudomeningocele, successfully treated with dual therapeutic intervention (CSF aspiration and EBP) using an ultrasound. This minimally-invasive intervention helped our patient resolve symptoms, avoid radiation, and make it cost-effective by avoiding surgical intervention and polypharmacy of general anesthesia.     

Value of epidural blood-patches for the treatment of spontaneous intracranial hypotension

OBJECTIVE: Spontaneous intracranial hypotension (SIH) is a rare syndrome. It is due most often to a spinal meningeal leak. Symptoms due to SIH are often difficult to treat and epidural blood-patch (BP) has been proposed. The aim was to evaluate the effects and the problems associated with lumbar blood-patch to treat SIH. STUDY DESIGN: Case series. PATIENTS AND METHODS: The diagnosis of SIH was made in six consecutive patients on clinical signs and radiological findings (CT-scan and MRI). A lumbar BP (L1-L2 level) was performed as soon as possible after diagnosis. A maximum of three procedures was allowed in case of failure of the initial BP. RESULTS: BP was effective and well tolerated for five patients (3 immediately after BP, 2 others patients needed 2 and 3 BP). In one patient, an incomplete response was observed and was related to a large CFS leak diagnosed by CT-myelogram. CONCLUSION: When the diagnosis of spontaneous intracranial hypotension is confirmed, a repeated blood patch lumbar procedure can be efficient to treat these patients.     

Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device

BACKGROUND AND OBJECTIVES: Complications related to cerebrospinal fluid (CSF) leak and low CSF pressure can occur following placement of an intrathecal drug delivery device. METHODS: A 58-year-old man with chronic, intractable lower back pain underwent implantation of an intrathecal drug delivery device. On the fourth postoperative day, he developed a postural headache and diplopia with findings compatible with left sixth cranial nerve palsy. The headache subsequently became constant and nonpostural. Cranial magnetic resonance imaging was obtained that showed the presence of a posterior subdural intracranial hematoma. Conservative treatment for postdural puncture headache did not improve the symptomatology. Therefore, an epidural blood patch was performed that produced rapid improvement and eventual resolution of symptoms. CONCLUSIONS: Intrathecal catheter implantation can result in CSF loss that might not resolve promptly with conservative therapy. In this case, epidural blood patch proved to be a safe and effective form of treatment.     

Primary empty sella syndrome in a series of 142 patients

OBJECT: The primary empty sella syndrome (ESS) represents a heterogeneous clinical picture characterized by endocrine disturbances and signs of intracranial hypertension. An increase in intracranial pressure (ICP) is proposed to be one of the involved pathogenetic factors. METHODS: The series included 142 patients who were observed during a period of 20 years. All patients underwent an ICP and cerebrospinal fluid (CSF) dynamics evaluation through the use of a lumbar constant-rate infusion test. Impairment of ICP and CSF dynamics was observed in 109 patients (76.8%). In 35 of the 36 patients affected by severe intracranial hypertension without rhinorrhea, improvement in adverse neurological symptoms was achieved after implanting a CSF shunt. Visual function, already seriously compromised before surgery, remained severely altered in one patient. In the group of 34 patients affected by rhinorrhea, CSF leakage was controlled using different surgical treatments: CSF shunt placement in 16 cases, surgical repair of the sellar floor in three, and both procedures in the remaining 13. Two patients refused any surgical treatment. CONCLUSIONS: The role of increased ICP in the pathogenesis and perpetuation of primary ESS has been confirmed. Adverse neurological signs and a CSF leak are correlated with an actual increase in ICP and are relieved after CSF shunt insertion. Cerebrospinal fluid rhinorrhea is more common than generally thought. Its resolution can be achieved using a careful diagnostic protocol and sometimes may require different surgical procedures.     

Treatment of spontaneous intracranial hypotension with percutaneous placement of a fibrin sealant. Report of four cases

Spontaneous intracranial hypotension due to a cerebrospinal fluid (CSF) leak in the spine is an important cause of new, daily persistent headaches. Most patients respond well to conservative treatments including epidural blood patching. Limited options for effective treatment are available for patients in whom these treatments fail. The authors treated four patients (mean age 38 years; range 26-43 years) with percutaneous placement of a fibrin sealant. All these patients presented with intractable positional headaches. The CSF leak was located in the lower cervical spine in three patients and in the lower thoracic spine in one patient. Four to 20 milliliters of fibrin sealant was injected at the site of the CSF leak. Two of the four patients became asymptomatic within days of the procedure and thus avoided surgery. There were no complications of this procedure. Percutaneous placement of a fibrin sealant is a safe, minimally invasive treatment for spontaneous spinal CSF leaks and should be considered in patients in whom conservative treatment has failed.     

Frameless stereotactic ventricular shunt placement for idiopathic intracranial hypertension

INTRODUCTION: Cerebrospinal fluid (CSF) shunting effectively reverses symptoms of idiopathic intracranial hypertension (IIH). Lumboperitoneal (LP) shunts have traditionally been used in patients with IIH due to a frequently undersized ventricular system. However, the advent of image-guided stereotaxis has enabled effective ventricular catheter placement in patients with IIH. We describe the first large series of frameless stereotactic ventriculoperitoneal (VP) shunting for patients with slit ventricles and IIH. METHODS: We describe the frameless stereotactic VP shunting technique for IIH in 32 procedures. Outcomes following shunt placement, time to shunt failure, and etiology of shunt failure are reported. RESULTS: A total of 21 patients underwent 32 ventricular shunting procedures (20 VP, 10 ventriculoatrial, 2 ventriculopleural). One hundred percent of shunts were successfully placed into slit ventricles, all requiring only one pass of the catheter under stereotactic guidance to achieve the desired location and CSF flow. There were no procedure-related complications and each ventricular catheter showed rapid egress of CSF. All (100%) patients experienced significant improvement of headache immediately after shunting. Ten percent of ventricular shunts failed at 3 months after insertion, 20% failed by 6 months, 50% failed by 12 months, and 60% failed by 24 months. Shunt revision was due to distal obstruction in 67%, overdrainage in 20%, and distal catheter migration or CSF leak in 6.5%. There were no shunt revisions due to proximal catheter obstruction or shunt infection. CONCLUSIONS: In our experience treating patients with IIH, frameless stereotactic ventricular CSF shunts were extremely effective at treating IIH-associated intractable headache, and continued to provide relief in nearly half of patients 2 years after shunting without many of the shunt-related complications that are seen with LP shunts. Placing ventricular shunts using image-guided stereotaxis in patients with IIH despite the absence of ventriculomegaly is an effective, safe treatment option.     

Postoperative hydrocephalus in cranial base surgery

The incidence of postoperative hydrocephalus and factors relating to it were analyzed in 257 patients undergoing cranial base surgery for tumor resection. A total of 21 (8%) patients developed postoperative hydrocephalus, and all required shunting, Forty-two (17%) patients developed cerebrospinal fluid (CSF) leak that required placement of external drainage systems (ventriculostomy or lumbar drain, or both); 10 (23%) of these 42 patients eventually needed shunt placement to stop the leak because of hydrocephalus. Prior craniotomy, prior radiation therapy, and postoperative CSF infection were also associated with an increased risk of developing hydrocephalus (48% versus 6%, 19% versus 8%, and 14% versus 7%, respectively). Prior radiation and postoperative CSF infection increased the risk of CSF leak in patients with hydrocephalus (30% versus 18% and 30% versus 9%, respectively). CSF leak and hydrocephalus commonly occurred in patients who underwent resection of a glomus tumor. In conclusion, 8% of patients who underwent cranial base surgery for tumors developed de novo hydrocephalus; half of them also had CSF leak in addition to hydrocephalus; and all required shunt placement for CSF diversion.     

Postoperative Hydrocephalus in Cranial Base Surgery

The incidence of postoperative hydrocephalus and factors relating to it were analyzed in 257 patients undergoing cranial base surgery for tumor resection. A total of 21 (8%) patients developed postoperative hydrocephalus, and all required shunting, Forty-two (17%) patients developed cerebrospinal fluid (CSF) leak that required placement of external drainage systems (ventriculostomy or lumbar drain, or both); 10 (23%) of these 42 patients eventually needed shunt placement to stop the leak because of hydrocephalus. Prior craniotomy, prior radiation therapy, and postoperative CSF infection were also associated with an increased risk of developing hydrocephalus (48% versus 6%, 19% versus 8%, and 14% versus 7%, respectively). Prior radiation and postoperative CSF infection increased the risk of CSF leak in patients with hydrocephalus (30% versus 18% and 30% versus 9%, respectively). CSF leak and hydrocephalus commonly occurred in patients who underwent resection of a glomus tumor. In conclusion, 8% of patients who underwent cranial base surgery for tumors developed de novo hydrocephalus; half of them also had CSF leak in addition to hydrocephalus; and all required shunt placement for CSF diversion.