Heavily T2-weighted MR myelography in patients with spontaneous intracranial hypotension: a case-control study

We performed whole-spine heavily T2-weighted magnetic resonance (MR) myelography using a single-shot fast spin-echo pulse sequence in 17 patients (8 M/9 F) with spontaneous intracranial hypotension (SIH) to detect abnormal cerebrospinal fluid (CSF) collections. In addition, a group of age- and sex-matched controls were recruited. Follow-up MR myelography was also done at 3 weeks. MR myelography showed three kinds of abnormal CSF collections in 15 patients with SIH (88%): epidural fluid collection (n = 15, 88%), C1-2 extraspinal collections (n = 6, 35%) and CSF collections along nerve roots in the lower cervical or upper thoracic spines (n = 6, 35%). One patient (6%) showed a meningeal diverticulum. In contrast, none of the controls showed these findings. Overall, MR myelography results helped in early diagnosis of SIH in four (24%) patients whose initial brain MRIs failed to show typical SIH findings. Follow-up MR myelography results were compatible with the clinical changes with kappa statistics of 0.52 and an agreement rate of 76%. Our study showed heavily T2-weighted MR myelography provided a rapid, non-invasive and high yield method to diagnose and follow-up patients with SIH. Whether the CSF collections along the nerve roots represent the ongoing leakage sites warrants further study.     

Spontaneous intracranial hypotension--a case report

Positional or orthostatic headache symptoms secondary to intracranial hypotension are usually seen as complications in patients after medical procedures, such as lumbar puncture. We describe a case of spontaneous intracranial hypotension (SIH) in a 43-year-old man without a previous history of headaches. He presented to the Emergency Department (ED) with a new-onset orthostatic headache without any history of recent medical procedure, such as lumbar puncture (LP). The ED evaluation included a normal neurologic examination and normal computed tomography (CT) scan of the brain. An LP showed low opening pressure, elevated protein, 46 RBCs and one lymphocyte. Subsequent evaluation with radionuclide cisternography confirmed a cerebrospinal fluid (CSF) leak in the area of the upper thoracic spine, and treatment with an epidural blood patch dramatically improved his symptoms. SIH is due to CSF leakage, usually in the area of the cervical or upper thoracic spine, often without a clear etiology. Conservative medical management including bed rest, oral hydration and caffeine intake is the usual first line treatment. An epidural blood patch is often a dramatically effective treatment that can be done once the presence and location of the leak is identified. Although mostly benign, this condition occasionally can be associated with the formation of clinically significant subdural fluid collections or hematomas. SIH is an increasingly recognized cause of headache.     

Spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is caused by leakage of cerebrospinal fluid (CSF), with resultant CSF hypovolemia and intracranial hypotension. Although in some patients SIH may be preceded by minor trauma, it often occurs in the absence of any identifiable initiating event. Orthostatic headache is the primary clinical manifestation, usually accompanied by one or more other symptoms of SIH. Diagnosis can be reached by a combination of imaging studies, which may include MRI with gadolinium, nuclear cisternography, and myelography. Treatment ranges from conservative management, such as bed rest and hydration, to invasive procedures, such as lumbar puncture with autologous blood patch, CT-guided fibrin glue injection at the site of the leak, and open surgical intervention. Outcomes vary from complete resolution of CSF leak with alleviation of symptoms to continued and/or recurrent leaks with chronic unremitting symptomatology.     

Atypical spontaneous intracranial hypotension (SIH) with nonorthostatic headache

BACKGROUND: Some patients with spontaneous intracranial hypotension (SIH) often do not demonstrate typical orthostatic headache, which is contrary to the typical SIH syndrome. They usually have an obscure and intermittent headache, regardless of their positional change. OBJECT: The objective of this study is to investigate the clinical course of atypical SIH that manifests with diffuse pachymeningeal enhancement, but no orthostatic headaches. METHODS: Between January 1997 and December 2005, we observed a total of 6 patients who revealed atypical presentations including nonpostural headaches and normal cerebrospinal fluid (CSF) pressure, despite the diffuse pachymeningeal enhancement seen on their MR images. For a comparison of the clinical features and the disease course, 13 other SIH patients with typical clinical manifestations were selected as a control group. RESULTS: Cerebrospinal fluid leakage sites were confirmed in only one patient through a variety of diagnostic tools; in contrast, definite focal CSF leakage sites were found in 12 of 13 patients with typical SIH. The 6 atypical SIH patients were treated with conservative treatment, including strict bed rest and intravenous hydration for 2 to 3 weeks. After a mean follow-up of 12 months, their headaches were gradually relieved after 2 to 3 weeks of conservative treatment only. CONCLUSIONS: All SIHs do not necessarily show the typical clinical manifestations. The atypical finding of SIH such as nonorthostatic headache or normal CSF pressure may be the result of a normal physiologic response to the typical SIH as a compensatory reaction. Therefore, when faced with patients showing findings compatible with SIH on the brain MR images, regardless of nonpostural headache, atypical SIH should be suspected.     

自发性低颅压综合征2例报告并文献复习

目的：探讨自发性低颅压综合征（Spontaneous Intracranial Hypotension,SIH）的临床和影像学特征,提高诊治水平。方法：对自发性低颅压2例报告并文献复习。结果：2例自发性低颅压均有典型的直立性头痛以及头颅核磁共振（MRI）增强扫描所示的硬脑膜广泛异常强化。其中1例虽然腰椎穿刺并无颅内压降低,但颈部MRI抑脂相提示脑脊液外漏。结论：脑脊液漏可能是导致自发性低颅压的主要原因,腰椎穿刺测压不是诊断的唯一依据,典型的临床表现和影像学征象有助于诊断,内科保守治疗无效时应考虑硬膜外血液补片法治疗。     

Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report

Donovan JS, Kerber CW, Donovan WH, Marshall LF. Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report.Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH₂O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.     

腰骶神经根疾病核磁共振脊髓造影的影像学分析

AIM: To illustrate the magnetic resonance(MR) myelography features in the disease of lumbosacral nerve roots. METHODS: MR myelography using heavily T2 weighted spin-echo imaging with fat suppression was performed in 75 cases with chronic pain of waist on a Siemens Magneton Impect 1.0 T MR unit Maximum intensity projection (MIP) was used for image reconstruction. RESULTS: The thecal maugins, nerve roots and nerve root sheaths were well demonstrated on MR myelography image. In 75 patients with chronic of waist, nerve root disease was found in 11 cases. 6 nerve root abnormality (8% ), 2 perineural cyst (3% ), 3 neurofibroma (4% ) had their own MR myelography features. CONCLUSION: MR myelography can show the morphologic and structural change of lumbosacral nerve roots. In MR myelography image, disease of lumbosacral nerve roots has a characteristic finding. MR myelography is very useful in diagnosis of nerve-root disease.     

Spontaneous intracranial hypotension syndrome: report of twelve cases

PURPOSE: To investigate clinical, MRI, and radioisotope findings and therapeutic outcome of the syndrome of spontaneous intracranial hypotension (SIH). BACKGROUND: Spontaneous intracranial hypotension is characterized by orthostatic headache, low CSF pressure, and MRI findings of diffuse pachymeningeal gadolinium enhancement without previous history of head trauma or lumbar puncture. Spontaneous CSF leakage from a spinal dural tear has been suggested as the underlying pathogenic mechanism of SIH. Most patients recover without sequelae, but subdural collections have been described in a few. METHODS: Twelve consecutive patients (10 females, 2 males, mean age 39 years) with headache related to the syndrome of spontaneous intracranial hypotension were investigated. RESULTS: Eleven patients presented orthostatic headache, one patient had continuous nonpostural headache. Additional clinical symptoms included nausea, vomiting, tinnitus, diplopia, and back pain. All the patients had low CSF opening pressure, seven had increased CSF albumin, and four had pleocytosis. Brain MRI showed diffuse pachymeningeal gadolinium enhancement. Other features included subdural fluid collections (hematoma/hygroma) in four patients, downward displacement of the brain in four patients, and enlargement of the pituitary gland in one patient. Radioisotope cisternography results indicated, in two patients, a CSF leakage site in the cervico-thoracic region, and in one patient showed limited ascent of the tracer to the cerebral convexity and early appearance of radioisotope in the bladder. All the patients had complete resolution of headache with conservative treatment. CONCLUSIONS: Patients with SIH have distinct MRI and sometimes radioisotope cisternographic abnormalities and generally respond favorably to conservative management.     

Spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is typically manifested by orthostatic headaches that may be associated with one or more of several other symptoms, including pain or stiffness of the neck, nausea, emesis, horizontal diplopia, dizziness, change in hearing, visual blurring or visual field cuts, photophobia, interscapular pain, and occasionally face numbness or weakness or radicular upper-limb symptoms. Cerebrospinal fluid (CSF) pressures, by definition, are quite low. SIH almost invariably results from a spontaneous CSF leak. Only very infrequently is this leak at the skull base (cribriform plate). In the overwhelming majority of patients, the leak is at the level of the spine, particularly the thoracic spine and cervicothoracic junction. Sometimes, documented leaks and typical clinical and imaging findings of SIH are associated with CSF pressures that are consistently within limits of normal. Magnetic resonance imaging of the head typically shows diffuse pachymeningeal gadolinium enhancement, often with imaging evidence of sinking of the brain, and less frequently with subdural fluid collections, engorged cerebral venous sinuses, enlarged pituitary gland, or decreased size of the ventricles. Radioisotope cisternography typically shows absence of activity over the cerebral convexities, even at 24 or 48 hours, and early appearance of activity in the kidneys and urinary bladder, and may sometimes reveal the level of the leak. Although various treatment modalities have been implemented, epidural blood patch is probably the treatment of choice in patients who have failed an initial trial of conservative management. When adequate trials of epidural blood patches fail, surgery can offer encouraging results in selected cases in which the site of the leak has been identified. Some of the spontaneous CSF leaks are related to weakness of the meningeal sac, likely in connection with a connective tissue abnormality.     

Management of an intracranial hypotension patient with diplopia as the primary symptom: A case report

BACKGROUNDIntracranial hypotension (IH) is a disorder involving cerebrospinal fluid (CSF) hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed, especially in these patients without the prototypical manifestation of an orthostatic headache. At present, the management of IH with both cranial nerve VI palsy and bilateral subdural hematomas (SDHs) is still unclear.CASE SUMMARYA 67-year-old male Chinese patient complained of diplopia on the left side for one and a half mo. Computed tomography revealed bilateral SDHs and a midline shift. However, neurotrophic drugs were not effective, and 3 d after admission, he developed a non-orthostatic headache and neck stiffness. Enhanced magnetic resonance imaging revealed dural enhancement as an additional feature, and IH was suspected. Magnetic resonance myelography was then adopted and showed CSF leakage at multiple sites in the spine, confirming the diagnosis of having IH. The patient fully recovered following multiple targeted epidural blood patch (EBP) procedures.CONCLUSIONIH is a rare disease, and to the best of our knowledge, IH with diplopia as its initial and primary symptom has never been reported. In this study, we also elucidated that it could be safe and effective to treat IH patients with associated cranial nerve VI palsy and bilateral SDHs using repeated EBP therapy.     

The cervical spine: radiologist's perspective

This article provides an essential curriculum in cervical spine radiology. It discusses the uses of plain radiographs, MR imaging, computed tomography (CT), and CT myelography, in addition to the methodologies of discography, epidural injections under visualization, and facet and nerve root injections. It explains how radiographic images of the cervical spine can differentiate tumors, inflammation, recent or prior trauma, and the range of discal, arthritic, neural, and vascular cervical pathologies and, just as importantly, when they cannot.     

Assessment of CSF flow dynamics using PC-MRI in spontaneous intracranial hypotension

(Headache 2012;52:808‐819) Aim.— Spontaneous intracranial hypotension (SIH) is caused by spontaneous cerebrospinal fluid (CSF) leaks and is known to cause orthostatic headaches. Phase‐contrast magnetic resonance imaging (PC‐MRI) is a non‐invasive technique that can be used to quantify variation in CSF flow. The aim of this study was to assess CSF flow dynamics using PC‐MRI in SIH. Materials and Methods.— Twenty‐five patients with a definitive diagnosis of SIH and 25 healthy subjects were evaluated with PC‐MRI. Magnetic resonance (MR) images were acquired using a 1.5‐T unit with an 8‐channel head coil. Differences between SIH patients and control subjects were assessed statistically using Wilcoxon's rank sum test, Spearman's rho test, or Pearson's chi‐square test, as appropriate. Results.— CSF flow volumes toward the third ventricle, CSF flow volumes toward the fourth ventricle, the absolute stroke volume, the peak systolic velocity, and the peak diastolic velocity in SIH patients were significantly smaller than those in control subjects (P < .0001). On the other hand, the net CSF flow volume (P = .9227) and the net CSF flow direction (P = .2472) for SIH patients and control subjects were not significantly different. Conclusions.— The results obtained by CSF flow analysis were directly related to values of CSF opening pressure, determined by lumbar puncture, and clinical findings, such as headache scores. Thus, CSF flow analysis with PC‐MRI, which has a short performance time and is non‐invasive, may contribute to assessment of SIH patients.     

Subdural haematoma in patients with spontaneous intracranial hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.     

The role of computerized tomography-myelography in a patient with spontaneous intracranial hypotension from multiple cerebrospinal fluid leaks

OBJECTIVES: To describe a patient with spontaneous intracranial hypotension (SIH) secondary to multiple sites of cerebrospinal fluid (CSF) leaks, a rarely described phenomenon. To compare computerized tomography-myelography with radionuclide cisternography as confirmatory diagnostic aids in SIH. METHODS: A patient with SIH had transient or no response to 2 thoracic epidural blood patches. A computerized tomography-myelography showed bilateral CSF leaks at T11-T12 and T12-L1 levels and on the left side of T10-T11. RESULTS: A left paramedian epidural blood patch was performed at T12-L1 under fluoroscopy guidance. Injection of 1 mL dye showed confinement of the dye at the left T11-L1 epidural space. The patient had 90% to 95% relief of her headache and complete relief at 4 months. She was asymptomatic 1 year after the last epidural blood patch. CONCLUSIONS: In a patient with SIH, a computerized tomography-myelography should be performed if an initial epidural blood patch is ineffective. This is to show the vertebral level and site(s) of CSF leak and to guide the physician to the ideal vertebral level for the epidural blood patch.     

Recurrence of spontaneous intracranial hypotension with subdural hematomas

A 59-year-old man developed postural headache associated with a low CSF pressure. A CT scan revealed no abnormal findings and the orthostatic symptoms resolved without treatment 6 weeks after onset. He was diagnosed as having spontaneous intracranial hypotension (SIH) and remained symptom-free until he experienced recurrence of postural headache 9 months later. A lumbar puncture demonstrated low CSF pressure, and a CT scan revealed slit-like ventricles with narrowing of the sulci, Sylvian fissures, and infratentorial cisterns, in addition to bilateral subdural masses. After draining the hematomas, his symptoms resolved completely, and a follow-up CT scan was normal. We hypothesize that recurrent SIH in this case was due to small recurrent tears of a root sleeve. This case emphasizes the importance of follow-up of SIH for at least 9 months after resolution of symptoms.     

Postural headache and cerebrospinal fluid leak: believing is seeing

A 33-year-old woman developed persistent postural headache following epidural anesthesia (L2-L3 level). Iohexol myelography (L5-S1 puncture) demonstrated no epidural extravasation of contrast material (Figure A), but subsequent computed tomography (CT) axial images (B, C) revealed leakage of dye through the needle track of the L5-S1 puncture (arrows). No leakage of contrast medium was found at the site of the L2-L3 epidural puncture.     

Spontaneous intracranial hypotension presenting as mental deterioration

A 55-year-old woman had new onset of postural headache followed by change of mental status 3 weeks later. Magnetic resonance imaging (MRI) of the brain and whole spine showed typical spontaneous intracranial hypotension (SIH) findings, bilateral subdural hematoma, and cerebrospinal fluid leakage over the T7-T9. Her headache and mentality improved after epidural blood patches. Early recognition and correct diagnosis are crucial for successful treatment in patients with SIH presenting with mental confusion.     

Cranial Magnetic Resonance Imaging in Spontaneous Intracranial Hypotension after Epidural Blood Patch

▪ Abstract:   Spontaneous intracranial hypotension (SIH) is a syndrome characterized by orthostatic headache, nausea, vomiting, photophobia, and diplopia. Subdural effusion, diffuse dural enhancement, dilatation of epidural veins, and increased height of hypophysis are cranial magnetic resonance (MR) imaging findings in SIH. Epidural blood patch is reportedly one of the effective treatment options. We present the follow-up MR imaging findings in a case of SIH after a successful epidural blood patch treatment. We propose that cranial MR imaging as an objective test to evaluate the success of epidural blood patch treatment. ▪     

Paradoxical postural headaches in cerebrospinal fluid leaks

Two patients with cerebrospinal fluid (CSF) leak, one at the level of fourth thoracic spine and another with undetermined level of leak, presented with paradoxical postural headaches in that the headaches were present when in a horizontal position and resolved if the patients were upright. One patient improved spontaneously and the other responded to a targeted epidural blood patch. Paradoxical postural headache is yet another headache type that can be associated with CSF leak and CSF volume depletion. Its mechanism is uncertain, but it could be related to congestion and dilatation of cerebral venous sinuses and large veins.     

Liquid crystal thermography in the evaluation of chronic back pain: a comparative study

This research involves the relative value of liquid crystal contact thermography (LCT) as compared to the physical examination, myelography, electromyography and CT scanning in the examination of 155 chronic low back pain patients. Thermograms were interpreted by two independent examiners as positive for nerve root compromise. Results demonstrate excellent interobserver reliability when used for this specific purpose and respectable correlations with the physical examination and EMG studies were obtained. Somewhat less correlation was found between LCT and the diagnostic procedures of CT scanning and myelography, especially in the postoperated patient. Liquid crystal contact thermography shows some promise as an adjunctive diagnostic tool in the assessment of chronic back pain patients with radicular symptoms, especially where further surgery is contemplated and the more structural tests of CT scanning and myelography may be falsely positive as a result of previous back surgery.