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.     

Treatment of spontaneous intracranial hypotension secondary to C-2 meningeal cyst by surgical packing--case report

A 41-year-old man presented with progressive worsening of postural headache. Computed tomography (CT) showed bilateral subdural hematomas without prior history of trauma. The diagnosis was spontaneous intracranial hypotension (SIH). Conservative treatment with oral steroids failed to prevent gradual deterioration of the patient's consciousness. CT myelography revealed massive cerebrospinal fluid (CSF) leakage between the C-1 and C-2 levels. The leak was repaired surgically via a laminectomy. A cyst, thought to be a meningeal cyst, was discovered adjacent to the right C-2 nerve root, and CSF was seen seeping out from around the cyst after a Valsalva maneuver. The presumed dural defect of the cyst was sealed by packing with muscle fragments and fibrin glue. The symptoms disappeared soon after surgery. He was discharged 1 month after surgery without deficits. Most SIH cases are benign and can be managed conservatively, or by the epidural blood patch method. Surgery is more invasive than the epidural blood patch method, but should be performed in patients with a high cervical lesion and massive CSF leakage.     

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.     

Spontaneous intracranial hypotension secondary to anterior thoracic osteophyte: Resolution after primary dural repair via posterior approach

INTRODUCTIONSpontaneous intracranial hypotension (SIH) is an uncommon syndrome widely attributed to CSF hypovolemia, typically secondary to spontaneous CSF leak. Although commonly associated with postural headache and variable neurological symptoms, one of the most severe consequences of SIH is bilateral subdural hematomas with resultant neurological deterioration.PRESENTATION OF CASEWe present the case of a patient diagnosed with SIH secondary to an anteriorly positioned thoracic osteophyte with resultant dural disruption, who after multiple attempts at nonsurgical management developed bilateral subdural hematomas necessitating emergent surgical intervention. The patient underwent a unilateral posterior repair of his osteophyte with successful anterior decompression. At 36 months follow up, the patient reported completely resolved headaches with no focal neurological deficits.DISCUSSIONWe outline our posterior approach to repair of the dural defect and review the management algorithm for the treatment of patients with SIH. We also examine the current hypotheses as to the origin, pathophysiology, diagnosis and treatment of this syndrome.CONCLUSIONA posterior approach was utilized to repair the dural defect caused by an anterior thoracic osteophyte in a patient with severe SIH complicated by bilateral subdural hematomas. This approach minimizes morbidity compared to an anterior approach and allowed for removal of the osteophyte and repair of the dural defect.     

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.     

Spontaneous intracranial hypotension complicating subdural hematoma: unilateral oculomotor nerve palsy caused by epidural blood patch

We report a case of a 41-year-old man with a 1-month history of postural headache due to spontaneous intracranial hypotension (SIH). His MRI revealed bilateral chronic subdural hematoma (CSH) and diffuse dural enhancement after gadolinium infusion. Indium-111 radionuclide cisternography revealed a CSF leak from the cervico-thoracic junction and rapid accumulation of radioisotope in the bladder. Postural headache failed to resolve with prolonged bed rest. The patient became restless and suffered recent memory disturbance. We therefore decided to treat the CSF leak with an epidural blood patch. After the procedure, the patient's headache resolved completely. However one day later, left oculomotor nerve palsy developed. MRI revealed enlargement of the left CSH with mass effect and midline shift. After hematoma drainage, the patient became alert and oculomotor palsy recovered gradually. To treat cases of CSH with SIH, the best method is to repair the CSF leakage and treat subdural hematoma at the same time. If the patient shows depressed consciousness, we recommend initial drainage of the subdural hematoma, because, following the repair of CSF leakage, mass effect such as uncal herniation may occur.     

Spontaneous intracranial hypotension associated with bilateral chronic subdural hematomas--case report

A 34-year-old female presented with spontaneous intracranial hypotension (SIH) manifesting as severe postural headache and meningism. Magnetic resonance (MR) imaging with gadolinium showed diffuse pachymeningeal enhancement. She developed bilateral chronic subdural hematomas 4 weeks after the onset of the symptoms. MR imaging showed descent of the midline structures of the brain. The bilateral chronic subdural hematomas were surgically drained, with no remarkable pressure. Postoperative MR imaging showed complete resolution of the pachymeningeal enhancement and relevation of the midline structures of the brain. SIH is an uncommon and probably unrecognized condition because of the usually benign course. However, this case emphasizes that SIH is not entirely benign. SIH should be considered if there is no identifiable risk for intracranial hemorrhage, particularly in young patients. Neurosurgical intervention for the treatment of the underlying cerebrospinal fluid leak may be required if SIH persists.     

Minimally invasive repair of spontaneous intracranial hypotension

Spontaneous spinal CSF leakage with the development of intracranial hypotension is a well-described entity. Cerebrospinal fluid leaks, mostly from the thoracic spine, are the major cause of spontaneous intracranial hypotension (SIH). Conservative treatment options include hydration, oral caffeine, and epidural blood patching. Alternatively, open surgical correction of meningeal diverticula is a therapeutic option. The authors describe 4 cases of spontaneous spinal CSF leakage producing symptoms of intracranial hypotension. All patients had multiple spinal diverticula with an identified leaking level. The patients were treated using a minimally invasive approach via surgical correction of the meningeal diverticulum.     

Delayed recurrence of spontaneous intracranial hypotension syndrome mimicking a Chiari I malformation: Case report with a review of the literature

IntroductionCerebellar tonsils descent seen on brain MRI is, along with other findings, a recognized radiological sign of possible spontaneous intracranial hypotension (SIH). The short-term outcome of SIH is usually favorable with symptoms improvement and reversibility of the low-lying tonsils. Nevertheless, data on the long-term outcome are lacking or inconsistent.Case ReportA 32-year-old woman presented to her general practitioner with a six months history of non-specific headaches. An MRI brain with gadolinium showed a 12mm tonsillar descent with no other remarkable findings. Headaches were initially managed conservatively as migraines. Following the onset of progressive upper back and shoulder pain at rest, nausea, photophobia and fogging in her vision, the patient was referred to our Department with a suspicion of symptomatic Chiari I malformation. After an in-depth anamnesis, it emerged a previous history of SIH, 14 years earlier, successfully treated conservatively in another center. A whole spine MRI confirmed the suspicion of recurrent SIH showing an anterior cervico-thoracic epidural fluid collection. The patient underwent an epidural blood patch with complete resolution of the symptoms and radiological signs.DiscussionTo our knowledge, this case is the first report of delayed recurrence of a SIH successfully treated conservatively over 10 years earlier. The etiopathogenesis and management of this rarity with literature review is discussed.ConclusionAn isolated cerebellar tonsil descent with no other remarkable findings on brain MRI and a previous history of SIH should always alert the clinician of a possible late recurrence of a CSF leak and avoid unnecessary Chiari I malformation surgical procedures.     

Spontaneous intracranial hypotension associated with transdural thoracic osteophyte reversed by primary. dural repair. Case report

Spontaneous intracranial hypotension (SIH) is an increasingly recognized syndrome associated with a specific set of clinical and imaging findings; however, determining the site of spinal cerebrospinal fluid (CSF) leakage in these patients is often difficult, and indications for surgical intervention need to be better defined. The authors report on a 55-year-old woman who presented with posture-related headache, disorientation, and memory impairment. Imaging features were consistent with SIH. Computerized tomography myelography demonstrated a large T2-3 anterior transdural osteophyte associated with a CSF fistula. After an unsuccessful trial of conservative therapy, the patient underwent median sternotomy, T2-3 discectomy and removal of osteophyte, which allowed adequate exposure for primary dural repair. Postoperatively, there was immediate and prolonged resolution of all of her symptoms. This case of SIH was caused by transdural penetration by an anterior osteophyte and CSF leakage in the upper thoracic spine, which was treated effectively by anterior exposure and primary dural repair. Aggressive surgical intervention may be required to treat upper thoracic CSF leaks refractory to other measures.     

Spontaneous intracranial hypotension syndrome treated with a double epidural blood patch

Spontaneous intracranial hypotension (SIH) is considered to be a very rare disease. It is characterised by an orthostatic headache in the absence of a past history of a trauma or a dural puncture. SIH is caused by a spontaneous spinal cerebrospinal fluid (CSF) leakage demonstrated by neuroradiological studies in most of the patients. Conservative treatment usually includes bed rest, hydration and administration of caffeine or steroids. However, when the patient is refractory to the conservative treatment, an epidural blood patch (EBP) is performed. We report a 34‐year‐old woman with SIH and no neuroradiologically demonstrable clear point of CSF leakage, who was treated with a double EBP at two different levels (lumbar and thoracic) in the same procedure. The patient was successfully managed, and she was still asymptomatic at the 18 months follow‐up. After review of literature, we observed that execution of a double EBP at the same time is not a common procedure for treatment of SIH. We consider that simultaneous use of two EBP could be useful as a novel treatment in those cases of SIH without demonstration of CSF leakage.     

Spontaneous intracranial hypotension associated with dural sinus thrombosis

A 32-year-old man presented with a rare case of spontaneous intracranial hypotension (SIH) associated with dural sinus thrombosis (DST) manifesting as severe postural headache which was relieved by lying down. Initial cerebrospinal fluid pressure was low. He was treated with hydration and rest under a diagnosis of SIH. Magnetic resonance (MR) imaging after 1 month showed signs of both DST and SIH. However, the patient did not demonstrate any of the classical symptoms associated with DST. The patient underwent an epidural blood patch procedure. His headache was relieved and MR imaging showed improvement of both SIH and DST. This case suggests that epidural blood patch may be effective in some cases of SIH associated with DST.     

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.     

Spectrum of subdural fluid collections in spontaneous intracranial hypotension

OBJECT: Spontaneous intracranial hypotension is a noteworthy but commonly misdiagnosed cause of new daily persistent headaches. Subdural fluid collections are frequent radiographic findings, but they can be interpreted as primary rather than secondary pathological entities, and uncertainties exist regarding their optimal management. The authors therefore reviewed their experience with subdural fluid collections in 40 consecutive patients with spontaneous spinal cerebrospinal fluid (CSF) leaks and intracranial hypotension. METHODS: The mean age of the 26 female and 14 male patients was 43 years (range 13-72 years). Subdural fluid collections were present in 20 patients (50%); 12 of these patients (60%) had subdural hygromas alone, and eight (40%) had subacute to chronic subdural hematomas (SDHs) associated with significant mass effect. The subdural hygromas resolved within several days to weeks following treatment of the underlying CSF leak. Three patients with SDHs underwent evacuation of the hematoma prior to the establishment of the diagnosis of spontaneous intracranial hypotension, but the SDHs did not resolve until the underlying spinal CSF leak was treated. In the remaining five patients, the CSF leak was treated primarily and the SDHs resolved over a 1- to 3-month period without the need for evacuation. CONCLUSIONS: Subdural fluid collections are common in spontaneous intracranial hypotension, varying in appearance from thin subdural hygromas to large SDHs associated with significant mass effect. These collections can be safely managed by directing treatment at the underlying CSF leak without the need for hematoma evacuation.     

Fatal cerebral and cerebellar hemorrhagic infarction after thoracoscopic microdiscectomy. Case report

The authors present a rare case of fatal cerebral and cerebellar hemorrhagic infarction following an uneventful thoracoscopic microdiscectomy. They hypothesize that this complication was associated with cortical venous thrombosis secondary to intracranial hypotension, which was caused by an unnoticed leak of cerebrospinal fluid (CSF) into the thoracic cavity. Cortical venous thrombosis and intrathoracic CSF were confirmed at autopsy. The former disorder is the most severe manifestation of the pathophysiological mechanism occurring to a lesser degree in patients affected by mild intracranial hypotension, and occurs more frequently in these patients. Intracranial hypotension (of an orthostatic nature or not) must be considered in the differential diagnosis of every patient who complains of headaches after thoracoscopic or open transthoracic microdiscectomy.     

Spinal magnetic resonance imaging of spontaneous intracranial hypotension in the early phase

A previously healthy 34-year-old woman and a previously healthy 35-year-old woman with spontaneous intracranial hypotension (SIH) presented within 1 week of the onset of symptoms. Brain magnetic resonance (MR) imaging with gadolinium demonstrated no abnormality, whereas spinal MR imaging revealed extradural fluid collection in both patients. Both patients were treated conservatively with bed rest and intravenous hydration. Their symptoms almost completely resolved. We suggest that spinal MR imaging findings of extradural fluid collection can help to establish the early diagnosis of SIH.     

Delayed diagnosis, due to the associated radiological abnormalities, of spontaneous intracranial hypotension caused by cerebrospinal fluid leakage at C1-2

Spontaneous intracranial hypotension (SIH) is an uncommon clinical entity that is often diagnosed after a delay, or it is misdiagnosed due to the variety of clinical presentations and the associated radiological findings. We present here a case of SIH associated with chronic subdural haematoma (SDH) and subarachnoid haemorrhage. Following the diagnosis of the SIH, the patient underwent injection of an epidural blood patch for the SIH and burr hole trephination was done for treating the chronic subdural haematoma.     

Recurrent spontaneous spinal cerebrospinal fluid leak associated with "nude nerve root" syndrome: case report

OBJECTIVE AND IMPORTANCE: Spontaneous spinal cerebrospinal fluid (CSF) leaks have been noted occasionally at multiple sites in the same patient, but recurrent spontaneous spinal CSF leaks have not been documented. We describe a patient with a recurrent CSF leak who was found at surgery to have an absence of the entire nerve root sleeve at multiple thoracic levels. CLINICAL PRESENTATION: A 29-year-old woman bodybuilder noted an excruciating orthostatic headache associated with nausea. The neurological examination was unremarkable, and a magnetic resonance imaging examination showed the typical changes of intracranial hypotension. Computed tomographic myelography showed an extensive bilateral lower cervical CSF leak. INTERVENTION: The patient underwent bilateral lower cervical nerve root explorations, and several small dural holes were found. The CSF leaks were repaired, but 3 months later, computed tomographic myelography showed a new CSF leak in the midthoracic area. A thoracic laminectomy was performed, and several nerve roots were found to be completely devoid of dura. After the CSF leaks were repaired, there was significant improvement in her headaches. CONCLUSION: A recurrent spontaneous spinal CSF leak may occur in patients with intracranial hypotension at a site previously documented not to be associated with a CSF leak. Absent nerve root sleeves may be found in patients with spontaneous spinal CSF leaks ("nude nerve root" syndrome), and these patients may be at increased risk of developing a recurrent CSF leak.     

False localizing sign of C1-2 cerebrospinal fluid leak in spontaneous intracranial hypotension

OBJECT: Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak is an important cause of new daily persistent headaches. Spinal neuroimaging is important in the treatment of these patients, particularly when direct repair of the CSF leak is contemplated. Retrospinal C1-2 fluid collections may be noted on spinal imaging and these are generally believed to correspond to the site of the CSF leak. The authors undertook a study to determine the significance of these C1-2 fluid collections. METHODS: The patient population consisted of a consecutive group of 25 patients (18 female and seven male) who were evaluated for surgical repair of a spontaneous spinal CSF leak. The mean age of the 18 patients was 38 years (range 13-72 years). All patients underwent computerized tomography myelography. Three patients (12%) had extensive retrospinal C1-2 fluid collections; the mean age of this woman and these two men was 41 years (range 39-43 years). The actual site of the CSF leak was located at the lower cervical spine in these patients and did not correspond to the site of the retrospinal C1-2 fluid collection. CONCLUSIONS: A retrospinal fluid collection at the C1-2 level does not necessarily indicate the site of the CSF leak in patients with spontaneous intracranial hypotension. This is an important consideration in the treatment of these patients because therapy may be inadvertently directed at this site.     

Intracranial hypotension caused by leakage of cerebrospinal fluid from the thecal sac after lumboperitoneal shunt placement. Case report

The authors describe a newly recognized complication of lumboperitoneal (LP) shunt placement, namely, intracranial hypotension from leakage of cerebrospinal fluid (CSF) through a defect in the lumbar dura created by the shunt catheter. They report on a 47-year-old obese woman with idiopathic intracranial hypertension who underwent routine placement of an LP shunt. Following surgery, her headache became worse. Two radionuclide shunt studies showed no anterograde tracer flow, suggesting either obstruction or a leak. After shunt reservoir manometry indicated low pressure, spinal magnetic resonance (MR) imaging was performed. The MR images revealed a CSF leak from the lumbar thecal sac. A computed tomography (CT) myelogram, performed by injection into the shunt reservoir, confirmed the presence of a leak by showing extravasation of contrast agent into the epidural space. The patient was treated by application of a CT-guided blood patch at the leak site. Catheter-associated CSF leak is an unusual cause of intracranial hypotension that can occur following LP shunt placement. This case report outlines the clinical features of this condition, documents the neuroradiological findings, and demonstrates successful treatment with a blood patch.