Abstracts 2015

This is a collection of selected publication abstracts about spinal CSF leak / intracranial hypotension from 2015.
* Abstract links are included. (click on the PMID number)
* Note that links to full-text are provided for open access papers (line below PMID).

How common is normal cerebrospinal fluid pressure in spontaneous intracranial hypotension?
Kranz PG, Tanpitukpongse TP, Choudhury KR, Amrhein TJ, Gray L.
Cephalalgia. 2015 Dec 17. pii: 0333102415623071. [Epub ahead of print]
To determine the proportion of patients with spontaneous intracranial hypotension (SIH) who had a cerebrospinal fluid (CSF) pressure >6 cm H2O and to investigate the clinical and imaging variables associated with CSF pressure (PCSF) in this condition.
We retrospectively reviewed 106 patients with SIH. PCSF was measured by lumbar puncture prior to treatment. Clinical and imaging variables – including demographic data, brain imaging results, symptom duration, and abdominal circumference – were collected. Univariate and multivariate analyses were performed to determine the correlation of these variables with PCSF.
Sixty-one percent of patients had a PCSF between 6 and 20 cm H2O; only 34% had a PCSF ≤6 cm H2O. The factors associated with increased PCSF included abdominal circumference (p < 0.001), symptom duration (p = 0.015), and the absence of brain magnetic resonance imaging findings of SIH (p = 0.003). A wide variability in PCSF was observed among all patients, which was not completely accounted for by the variables included in the model. CONCLUSIONS: Normal CSF pressure is common in patients with SIH; the absence of a low opening pressure should not exclude this condition. Body habitus, symptom duration, and brain imaging are correlated with PCSF measurements, but these factors alone do not entirely explain the wide variability in observed pressures in this condition and this suggests the influence of other factors. PMID: 26682575

Spontaneous intracranial hypotension: Characteristics of the serious form in a series of 24 patients.
Idrissi AL, Lacour JC, Klein O, Schmitt E, Ducrocq X, Richard S.
World Neurosurg. 2015 Dec;84(6):1613-20. doi: 10.1016/j.wneu.2015.07.002. Epub 2015 Jul 9.
Recommended treatments for spontaneous intracranial hypotension (SIH) range from bed rest only to neurosurgery. However, the serious form of SIH is poorly defined. A better description of patient characteristics and their outcome may help define therapeutic options.
We reviewed 24 cases of patients with SIH and separated them into two groups according to whether or not they presented with signs of severity at admission: disturbance of consciousness, subdural hematomas (SDHs) and cerebral venous thrombosis.
Nine patients (37%) were classified as having a serious form of SIH: six (25%) presented SDHs; three (12%) disturbance of consciousness; and one (4%) cerebral venous thrombosis. Bed rest and epidural blood patches (EBPs) were sufficient to treat all patients in the non-serious form group and four patients in the serious form group. Two patients (8%) had to undergo cerebrospinal fluid leak repair, and three others (12%) evacuation of SDHs. Outcome was good in both groups, with only one (4%) death due to extensive SDHs. Times to diagnosis in the serious form group (63 vs. 35 days, p=0.052), and to recovery (9 months vs. 5 months, p=0.088) tended to be higher without reaching difference.
The presence of SDHs, disturbance of consciousness and a trend toward a longer time to diagnosis and recovery seem to define the serious form of SIH. These patients may require exploration and surgical repair of cerebrospinal fluid leak, only after failure of conservative measures – bed rest and time – and EBP, with good outcome.
PMID: 26165144

A short review on a complication of lumbar spine surgery: CSF leak
Menon SK, Onyia CU.
Clin Neurol Neurosurg. 2015 Dec;139:248-51. doi: 10.1016/j.clineuro.2015.10.013. Epub 2015 Oct 23.
Cerebrospinal fluid (CSF) leak is a common complication of surgery involving the lumbar spine. Over the past decades, there has been significant advancement in understanding the basis, management and techniques of treatment for post-operative CSF leak following lumbar spine surgery. In this article, we review previous work in the literature on the various factors and technical errors during or after lumbar spine surgery that may lead to this feared complication, the available options of management with focus on the various techniques employed, the outcomes and also to highlight on the current trends. We also discuss the presentation, factors contributing to its development, basic concepts and practical aspects of the management with emphasis on the different techniques of treatment. Different outcomes following various techniques of managing post-operative CSF leak after lumbar spine surgery have been well described in the literature. However, there is currently no most ideal technique among the available options. The choice of which technique to be applied in each case is dependent on each surgeon’s cumulative experience as well as a clear understanding of the contributory underlying factors in each patient, the nature and site of the leak, the available facilities and equipment.
PMID: 26523872

Audiovestibular impairments associated with intracranial hypotension.
Choi JH, Cho KY, Cha SY, Seo JD, Kim MJ, Choi YR, Kim SH, Kim JS, Choi KD.
J Neurol Sci. 2015 Oct 15;357(1-2):96-100. doi: 10.1016/j.jns.2015.07.002. Epub 2015 Jul 4.
To investigate the patterns and mechanisms of audiovestibular impairments associated with intracranial hypotension.
We had consecutively recruited 16 patients with intracranial hypotension at the Neurology Center of Pusan National University Hospital for two years. Spontaneous, gaze-evoked, and positional nystagmus were recorded using 3D video-oculography in all patients, and the majority of them also had pure tone audiometry and bithermal caloric tests.
Of the 16 patients, five (31.3%) reported neuro-otological symptoms along with the orthostatic headache while laboratory evaluation demonstrated audiovestibular impairments in ten (62.5%). Oculographic analyses documented spontaneous and/or positional nystagmus in six patients (37.5%) including weak spontaneous vertical nystagmus with positional modulation (n=4) and pure positional nystagmus (n=2). One patient presented with recurrent spontaneous vertigo and tinnitus mimicking Meniere’s disease, and showed unidirectional horizontal and torsional nystagmus with normal head impulse tests during the attacks. Bithermal caloric tests were normal in all nine patients tested. Audiometry showed unilateral (n=6) or bilateral (n=1) sensorineural hearing loss in seven (53.8%) of the 13 patients tested.
Intracranial hypotension frequently induces audiovestibular impairments. In addition to endolymphatic hydrops and irritation of the vestibulocochlear nerve, compression or traction of the brainstem or cerebellum due to loss of CSF buoyancy may be considered as a mechanism of frequent spontaneous or positional vertical nystagmus in patients with intracranial hypotension.
PMID: 26165775

Incidence and treatment of delayed symptoms of CSF leak following lumbar spinal surgery
Khazim R1, Dannawi Z, Spacey K, Khazim M, Lennon S, Reda A, Zaidan A.
Eur Spine J. 2015 Sep;24(9):2069-76. doi: 10.1007/s00586-015-3830-4. Epub 2015 Feb 25.
Dural tear (DT) resulting in cerebrospinal fluid (CSF) leak is a common complication of spinal surgery. Most cases of DT are recognised and addressed intraoperatively; however, a small percentage of cases may present at a later stage with delayed symptoms of CSF leak, either due to an unrecognised intraoperative DT or as a result of a de novo delayed DT. Apart from few reports describing delayed symptomatic CSF leaks, most studies tend not to separate intraoperatively recognised DTs from delayed symptomatic CSF leaks. To our knowledge, there are no long-term studies describing specifically the incidence and management of this complication. The aim of this study is to determine the incidence of late presentation of dural tear (LPDT) following lumbar spinal surgery, its treatment, associated complications and clinical outcomes from long-term follow-up in a consecutive series of patients.
A retrospective review was conducted on 2052 consecutive patients who underwent spinal surgery by two spinal surgeons from 2000 to 2005 and 2007 to 2013 at two institutions.
A total of 2052 patient records were reviewed. Seventeen patients (0.83 %) were found to have LPDT, unrecognised intraoperatively. Fifteen patients required surgical intervention, one patient was treated with insertion of a subarachnoid drain and only one patient settled with conservative measures. Out of the 15 patients who underwent surgery, two patients required another operation and 2 patients were treated with a subarachnoid drain. At 9 months mean follow-up, there was no significant difference in outcome in cases with LPDT compared to those without.
A delayed symptomatic presentation of DT unrecognised intraoperatively is a specific complication that needs to be recognised and treated appropriately. A high suspicion and vigilance can help discover and address delayed CSF leaks with no long-term sequelae.
PMID: 25711914

Intrathecal preservative-free normal saline challenge magnetic resonance myelography for the identification of cerebrospinal fluid leaks in spontaneous intracranial hypotension.
Griauzde J, Gemmete JJ, Pandey AS, Chaudhary N.
J Neurosurg. 2015 Sep;123(3):732-6. doi: 10.3171/2014.12.JNS142057. Epub 2015 Jul 3.
OBJECT A CSF leak can be difficult to locate in patients who present with spontaneous intracranial hypotension (SIH). The purpose of this case series was to describe the authors’ experience with intrathecal preservative-free normal saline challenge coupled with contrast-enhanced MR myelography (CEMRM), which was used to provoke and detect a CSF leakage site in patients with SIH.
METHODS The authors performed a retrospective review of the records of patients who underwent preservative-free normal saline challenge followed by intrathecal gadolinium (Gd) contrast infusion and MR myelography from 2010 to 2012.
RESULTS The records survey identified 5 patients who underwent 6 procedures. Intrathecal preservative-free normal saline challenge followed by CEMRM identified a CSF leak during 5 of the 6 procedures. Previous CT myelograms were available from 4 patients, which did not reveal a leakage site. A CT myelogram of 1 patient showed a single leak, but the authors’ saline challenge-CEMRM technique identified multiple additional leakage sites. Three patients exhibited transient postprocedural symptoms related to the saline infusion, but no long-term or permanent adverse effects related to the procedure were observed.
CONCLUSIONS Instillation of preservative-free normal saline into the thecal sac followed by intrathecal Gd infusion is a safe technique that may increase the detection of a CSF leak on MR myelography images in patients with SIH.
PMID: 26140486

A case-series study on clinical presentation, neuroradiological characteristics, and outcome of 56 consecutive patients suspected of having spontaneous intracranial hypotension.
Arai M
Rinsho Shinkeigaku. 2015;55(9):623-9. doi: 10.5692/clinicalneurol.cn-000716. Epub 2015 Jul 7.
The author reviewed the clinical records and neuroradiologic examinations of 86 consecutive patients with orthostatic headache who visited our clinic between April 1995 and December 2014. Fifty-six patients were suspected to have spontaneous intracranial hypotension (SIH). The baseline characteristics of these patients were essentially similar to those reported in other published case series of SIH: female preponderance, mean age of approximately 40 years, and frequent association with nausea, hearing disturbances, or vertigo. In 43 patients who underwent gadolinium-enhanced MRI, 15 had partial dural enhancement and 15 had diffuse enhancement. Of 13 patients who underwent radionuclide cisternography, a direct finding of cerebrospinal fluid (CSF) leakage was demonstrated in six patients. Ordinal scales were formulated for regression of the extent of dural enhancement on cranial MRI (none: 0, partial: 1, diffuse: 2) and severity of orthostatic headache (not so severe: 1, severe: 2). Ordinal logistic regression analysis demonstrated that the extent of dural enhancement was negatively associated with the severity of orthostatic headache. A possible explanation was that patients suspected of having SIH who showed severe orthostatic headache may lack the ability to compensate for CSF loss. Epidural blood patch (EBP) is targeted at the CSF leak site or at the lumbar level when the site of CSF leak has not been determined. The interval from EBP to disappearance of orthostatic headache did not significantly differ in six patients treated with targeted EBP and five patients with lumbar EBP. Linear regression analysis demonstrated that the duration of orthostatic headache was associated with the interval from onset of headache to initial visit to our clinic, with the slope of the regression line 1.243 and intercept 14.8 days. Thus, early diagnosis of SIH appeared to correlate with earlier disappearance of orthostatic headache. No other factors were found to predict the outcome of SIH.
PMID: 26156257

Spontaneous Intracranial Hypotension.
Mokri B.
Continuum (Minneap Minn). 2015 Aug;21(4, Headache):1086-1108.
Spontaneous intracranial hypotension results from CSF volume depletion, nearly always from spontaneous CSF leaks. Spontaneous intracranial hypotension is increasingly diagnosed in practice; the number of atypical, unconfirmed, and doubtful cases is also increasing, as are treatment failures. These confront neurologists and create many challenges. This review provides neurologists with a guide to diagnosis, evaluation, and treatment of spontaneous intracranial hypotension.
The clinical spectrum of spontaneous intracranial hypotension is expanding. Spontaneous CSF leak is considered a disorder with a variety of clinical manifestations and imaging features, sometimes quite different from what may be seen after dural puncture. The anatomy of the spontaneous CSF leak is frequently complex, with contributions from disorders of the connective tissue matrix and associated preexisting areas of dural weakness and meningeal diverticula. To locate the site of the leak, CT myelography is still the study of choice. For rapid-flow leaks, dynamic CT myelography has been very helpful, while slow-flow leaks can remain a lingering challenge. The fundamental question of whether a CSF leak is present in uncertain cases can be best answered by radioisotope cisternography. In most cases, epidural blood patch is the main treatment; however, bilevel or multilevel epidural injections are gaining some momentum as treatment for selected cases.
This article outlines various clinical aspects of spontaneous intracranial hypotension, including headache characteristics, CSF changes, and imaging findings and their underlying mechanisms, as well as treatments and disease complications.
PMID: 26252593

A Practical Approach to the Diagnosis of Spontaneous Intracranial Hypotension
Steenerson K, Halker R.
Curr Pain Headache Rep. 2015 Aug;19(8):509.
Spontaneous intracranial hypotension can be difficult to diagnose as there are a number of tests available and knowing how to appropriately choose amongst them is not always easy. In this article, we will review the available diagnostic options and provide a practical approach to the workup of a patient with suspected intracranial hypotension.
PMID: 26077206

Thoracic Epidural Blood Patches in the Treatment of Spontaneous Intracranial Hypotension: A Retrospective Case Series.
Feltracco P, Galligioni H, Barbieri S, Ori C.
Pain Physician. 2015 Jul-Aug;18(4):343-8.
Spontaneous intracranial hypotension (SIH) results from leaks developing in the dura mater. The major symptom is orthostatic headache which gradually disappears after lying down. Lumbar epidural blood patches (EBPs) can be effective in relieving headaches, however, thoracic and cervical EBPs have also been applied to alleviate the symptoms.
Retrospective collection of the main characteristics of SIH, site and amount of blood injection, and clinical outcomes of 18 patients who underwent thoracic EBPs for intractable SIH.
Retrospective case series
All thoracic autologous EBPs except 3 were performed in the sitting position. Patients undergoing epidural puncture at lower thoracic levels (T10-T12) received 25 mL of autologous blood, 15 mL and 18 mL were injected at spinal segments T5-T7 (mid-thoracic) and T2-T4 (upper- thoracic), respectively. Thoracic EBPs did not lead to immediate resolution of symptoms in 3 of 18 patients; one of them underwent early repetition with complete headache relief, one refused a second EBP, and one experienced partial resolution, followed by a recurrence, and then satisfactory improvement with a second high thoracic EBP. In long-term follow-up only 2 patients complained of symptoms or relapses.
Retrospective nature of the case series, single center experience.
Performing thoracic-targeted EBPs as the preferred approach theoretically improves results with respect to those observed with lumbar EBPs. The immediate response was comparable with that of other reports, but the long-term success rate (90%) turned out to be very effective in terms of both quality of headache relief and very low incidence of recurrence.
PMID: 26218937

Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study.
Wang YF, Fuh JL, Lirng JF, Chen SP, Hseu SS, Wu JC, Wang SJ.
Brain. 2015 Jun;138(Pt 6):1492-8. doi: 10.1093/brain/awv016. Epub 2015 Feb 13.
The spatial distribution and clinical correlation of cerebrospinal fluid leakage after lumbar puncture have not been determined. Adult in-patients receiving diagnostic lumbar punctures were recruited prospectively. Whole-spine heavily T2-weighted magnetic resonance myelography was carried out to characterize post-lumbar puncture spinal cerebrospinal fluid leakages. Maximum rostral migration was defined as the distance between the most rostral spinal segment with cerebrospinal fluid leakage and the level of lumbar puncture. Eighty patients (51 female/29 male, mean age 49.4 ± 13.3 years) completed the study, including 23 (28.8%) with post-dural puncture headache. Overall, 63.6% of periradicular leaks and 46.9% of epidural collections were within three vertebral segments of the level of lumbar puncture (T12-S1). Post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks (length 3.0 ± 2.5 versus 0.9 ± 1.9 segments, P = 0.001; maximum rostral migration 4.3 ± 4.7 versus 0.8 ± 1.7 segments, P = 0.002) and epidural collections (length 5.3 ± 6.1 versus 1.0 ± 2.1 segments, P = 0.003; maximum rostral migration 4.7 ± 6.7 versus 0.9 ± 2.4 segments, P = 0.015). In conclusion, post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks and epidural collections. Further, visualization of periradicular leaks was not restricted to the level of dural defect, although two-thirds remained within the neighbouring segments.
PMID: 25688077

False localizing sign of cervico-thoracic CSF leak in spontaneous intracranial hypotension
Schievink WI, Maya MM, Chu RM, Moser FG.
Neurology. 2015 Jun 16;84(24):2445-8.
Spontaneous spinal CSF leaks are an important cause of new-onset headaches. Such leaks are reported to be particularly common at the cervico-thoracic junction. The authors undertook a study to determine the significance of these cervico-thoracic CSF leaks.
The patient population consisted of a consecutive group of 13 patients who underwent surgery for CSF leak repair based on CT myelography showing CSF extravasation at the cervico-thoracic junction but without any evidence of an underlying structural lesion.
The mean age of the 9 women and 4 men was 41.2 years. Extensive extrathecal longitudinal CSF collections were demonstrated in 11 patients. At surgery, small leaking arachnoid cysts were found in 2 patients. In the remaining 11 patients, no clear source of CSF leakage could be identified at surgery. Resolution of symptoms was achieved in both patients with leaking arachnoid cysts, but in only 3 of the 11 patients with negative intraoperative findings. Postoperative spinal imaging was performed in 9 of the 11 patients with negative intraoperative findings and showed persistence of the longitudinal intraspinal extradural CSF. Further imaging revealed the site of the CSF leak to be ventral to the thoracic spinal cord. Five of these patients underwent microsurgical repair of the ventral CSF leak with resolution of symptoms in all 5 patients.
Cervico-thoracic extravasation of dye on myelography does not necessarily indicate the site of the CSF leak. Treatment directed at this site should not be expected to have a high probability of sustained improvement of symptoms.
PMID: 25979700

Hyperprolactinemia due to spontaneous intracranial hypotension
Schievink WI, Nuño M, Rozen TD, Maya MM, Mamelak AN, Carmichael J, Bonert VS
J Neurosurg. 2015 May;122(5):1020-5.
OBJECT: Spontaneous intracranial hypotension is an increasingly recognized cause of headaches. Pituitary enlargement and brain sagging are common findings on MRI in patients with this disorder. The authors therefore investigated pituitary function in patients with spontaneous intracranial hypotension.
METHODS: Pituitary hormones were measured in a group of 42 consecutive patients with spontaneous intracranial hypotension. For patients with hyperprolactinemia, prolactin levels also were measured following treatment. Magnetic resonance imaging was performed prior to and following treatment.
RESULTS: The study group consisted of 27 women and 15 men with a mean age at onset of symptoms of 52.2 ± 10.7 years (mean ± SD; range 17-72 years). Hyperprolactinemia was detected in 10 patients (24%), ranging from 16 ng/ml to 96.6 ng/ml in men (normal range 3-14.7 ng/ml) and from 31.3 ng/ml to 102.5 ng/ml in women (normal range 3.8-23.2 ng/ml). In a multivariate analysis, only brain sagging on MRI was associated with hyperprolactinemia. Brain sagging was present in 60% of patients with hyperprolactinemia and in 19% of patients with normal prolactin levels (p = 0.02). Following successful treatment of the spontaneous intracranial hypotension, hyperprolactinemia resolved, along with normalization of brain MRI findings in all 10 patients.
CONCLUSIONS: Spontaneous intracranial hypotension is a previously undescribed cause of hyperprolactinemia. Brain sagging causing distortion of the pituitary stalk (stalk effect) may be responsible for the hyperprolactinemia.
PMID: 25380110

Posterior Reversible Encephalopathy Syndrome Secondary to CSF Leak and Intracranial Hypotension: A Case Report and Literature Review
Hammad T, DeDent A, Algahtani R, Alastal Y, Elmer L, Medhkour A, Safi F, Assaly R.
Case Rep Neurol Med. 2015;2015:538523. Epub 2015 May 27.
Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical neuroradiological condition characterized by insidious onset of neurological symptoms associated with radiological findings indicating posterior leukoencephalopathy. PRES secondary to cerebrospinal fluid (CSF) leak leading to intracranial hypotension is not well recognized etiology of this condition. Herein, we report a case of PRES that occurred in the setting of CSF leak due to inadvertent dural puncture. Patient underwent suturing of the dural defect. Subsequently, his symptoms resolved and a repeated brain MRI showed resolution of brain lesions. The pathophysiology and mechanistic model for developing PRES in the setting of intracranial hypotension were discussed. We further highlighted the importance of tight blood pressure control in patients with CSF leak and suspected intracranial hypotension because they are more vulnerable to develop PRES with normal or slightly elevated bleed pressure values.
PMID: 26106495
PMCID: PMC4461750

Posterior thoracic laminoplasty with dorsal, intradural identification of ventral defect and transdural discectomy for a spontaneous cerebrospinal fluid leak: case report
Pricola Fehnel K, Borges LF.
J Neurosurg Spine. 2015 May;22(5):478-82. doi: 10.3171/2014.10.SPINE14439. Epub 2015 Feb 6.
Spontaneous intracranial hypotension (SIH) has been increasingly reported in the literature concomitant with the improved sensitivity of imaging modalities. Although typically associated with meningeal weakening, a handful of cases of SIH secondary to thoracic disc osteophytes have been reported. Five of 7 reported cases were treated with epidural blood patch (EBP) alone while 2 required surgical management. There is no standard operative approach; both anterior and posterolateral approaches can be cumbersome and associated with morbidity, particularly in young, healthy patients. The authors report a case of SIH in which a ventral dural tear secondary to a calcified thoracic disc was repaired via posterior thoracic laminoplasty with dorsal durotomy and intradural exposure of the ventral defect with transdural discectomy followed by primary closure. A 34-year-old man presented with low-pressure headaches following axial load injury from a ski accident 5 years earlier. The patient’s symptoms were refractory to a trial of conservative treatment and EBP, and he developed bilateral upper-extremity paresthesias. MRI of the spine demonstrated an extrathecal collection spanning the thoracic spine, and dynamic CT myelography identified contrast extravasation adjacent to a calcified paramedian disc at T9-10. The patient underwent posterior laminoplasty with neuromonitoring. A ventral dural defect was visualized via a dorsal durotomy, the penetrating disc osteophyte was removed transdurally, and the ventral and dorsal dura maters were closed primarily. Both somatosensory and motor evoked potentials were unchanged during surgery. The patient has remained asymptomatic more than 10 months postoperatively and he has resumed work as a surgeon. Cases of SIH secondary to a calcified thoracic disc are rare with little precedent as to optimal surgical intervention. This case illustrates the potential usefulness of posterior laminectomy in nonmyelopathic patients in whom there is no evidence of canal compromise and for whom neuromonitoring is available. Additionally, surgeon experience and patient preference may guide surgical planning.
PMID: 25658466

Spontaneous Intracranial Hypotension as First Symptom of Aneurysms-Osteoarthritis Syndrome: A Case Report
Koppen H, Baars MJ, van Gils A, Vis JC.
Headache. 2015 May;55(5):711-2.
No abstract available
PMID: 25877775

Risk factors for subdural haematoma in patients with spontaneous intracranial hypotension
Xia P, Hu XY, Wang J, Hu BB, Xu QL, Zhou ZJ, Lou M.
PLoS One. 2015 Apr 8;10(4):e0123616. eCollection 2015.
Subdural haematoma (SDH) is a potentially life-threatening complication in patients with spontaneous intracranial hypotension (SIH). In serious cases, SIH patients who present with SDHs develop neurological deficits, a decreased level of consciousness, or cerebral herniation, and may even require an urgent neurosurgical drainage. Despite numerous publications on SDHs, few report its potential risk factors in patients with SIH. In this study, we retrospectively investigated 93 consecutive SIH patients and divided them into an SDH group (n = 25) and a non-SDH (NSDH) group (n = 68). The clinical and radiographic characteristics of these 93 patients were analyzed, and then univariate analysis and further multiple logistic regression analysis were performed to identify the potential risk factors for the development of SDHs. The univariate analysis showed that advanced age, male gender, longer clinical course, dural enhancement, and the venous distension sign were associated with the development of SDHs. However, multivariate analysis only included the latter three factors. Our study reveals important radiological manifestations for predicting the development of SDHs in patients with SIH.
PMID: 25853681
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Ultrafast dynamic computed tomography myelography for the precise identification of high-flow cerebrospinal fluid leaks caused by spiculated spinal osteophytes.
Thielen KR1, Sillery JC, Morris JM, Hoxworth JM, Diehn FE, Wald JT, Rosebrock RE, Yu L, Luetmer PH.
J Neurosurg Spine. 2015 Mar;22(3):324-31.
OBJECT Precise localization and understanding of the origin of spontaneous high-flow spinal CSF leaks is required prior to targeted treatment. This study demonstrates the utility of ultrafast dynamic CT myelography for the precise localization of high-flow CSF leaks caused by spiculated spinal osteophytes.
METHODS This study reports a series of 14 patients with high-flow CSF leaks caused by spiculated spinal osteophytes who underwent ultrafast dynamic CT myelography between March 2009 and December 2010. There were 10 male and 4 female patients, with an average age of 49 years (range 37-74 years). The value of ultrafast dynamic CT myelography in depicting the CSF leak site was qualitatively assessed.
RESULTS In all 14 patients, ultrafast dynamic CT myelography was technically successful at precisely demonstrating the site of the CSF leak, the causative spiculated osteophyte piercing the dura, and the relationship of the implicated osteophyte to adjacent structures. Leak sites included 3 cervical, 11 thoracic, and 0 lumbar levels, with 86% of the leaks occurring from C-5 to T-7. Information obtained from the ultrafast dynamic CT myelogram was considered useful in all treated CSF leaks.
CONCLUSIONS Spinal osteophytes piercing the dura are a more frequent cause of high-flow CSF leaks than previously recognized. Ultrafast dynamic CT myelography adds value beyond standard dynamic myelography or digital subtraction myelography in the diagnosis and anatomical characterization of high-flow spinal CSF leaks caused by these osteophytes. This information allows for appropriate planning for percutaneous or surgical treatment.
PMID: 25555057

Changing the needle for lumbar punctures: Results from a prospective study
Engedal TS, Ørding H, Vilholm OJ.
Clin Neurol Neurosurg. 2015 Mar;130:74-9.
Post-dural puncture headache (PDPH) is a common complication of diagnostic lumbar punctures. Both a non-cutting needle design and the use of smaller size needles have been shown to greatly reduce the risk of PDPH. Nevertheless, larger cutting needles are still widely used. This study describes the process of changing the needle in an outpatient clinic of a Danish neurology department.
Prospective interventional trial. Phase 1: 22G cutting needle. Phase 2: 25G non-cutting needle. Practical usability of each needle was recorded during the procedure, while the rate of PDPH and the occurrence of socioeconomic complications were acquired from a standardized questionnaire.
651 patients scheduled for diagnostic lumbar punctures were screened for participation and 501 patients were included. The response rate was 80% in both phases. In phase 2, significant reductions were observed in occurrence of PDPH (21 vs 50, p=0.001), number of days spent away from work (55 vs 175, p<0.001), hospitalizations (2 vs 17, p<0.001), and number of bloodpatch treatments (2 vs 10, p=0.019). Furthermore, during the procedure, both the need for multiple attempts (30% vs 44%, p=0.001), and the failure-rate of the first operator (17% vs 29%, p=0.005) were reduced. CONCLUSIONS: Our study showed that smaller, non-cutting needles reduce the incidence of PDPH and are easily implemented in an outpatient clinic. Changing the needle resulted in fewer socioeconomic complications and fewer overall costs, while also reducing procedural difficulty.
PMID: 25590665
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A Wearable Epidural Catheter Infusion System for Patients With Intractable Spontaneous Intracranial Hypotension
Schievink WI, Rosner HL, Louy C.
Reg Anesth Pain Med. 2015 Jan-Feb;40(1):49-51.
Spontaneous intracranial hypotension is an important cause of secondary headaches, and most patients respond well to epidural blood patching or direct repair of the underlying spinal cerebrospinal fluid leak. However, options are limited for those patients who have exhausted these traditional treatments, especially when spinal imaging is normal. We describe a wearable epidural catheter infusion system for patients with intractable spontaneous intracranial hypotension.
Six patients with intractable spontaneous intracranial hypotension (4 women and 2 men; mean age, 53 years; mean duration of symptoms, 50 months) underwent placement of a permanent indwelling spinal epidural catheter attached to an external infusion pump. The Migraine Disability Assessment questionnaire was used to assess the severity of the symptoms, before and during treatment.
The infusion resulted in complete or near-complete symptom relief in 5 of 6 patients (Migraine Disability Assessment score decreased from grade IV to grade I or II). However, the epidural catheter infusion system was removed in 2 patients because of infection, in 1 patient because of delayed failure to provide adequate symptom control, and in 1 patient because of minimal symptom relief. Two patients reported excellent and sustained symptom relief over 27 and 36 months of follow-up.
This wearable epidural catheter infusion system showed promising efficacy results but the high rate of complications limits its use to a very select group of patients.
PMID: 25474623

Retrospective study of epidural blood patch use for spontaneous intracranial hypotension
Joo EY, Hwang BY, Kong YG, Lee JH, Hwang BS, Suh JH.
Reg Anesth Pain Med. 2015 Jan-Feb;40(1):58-61.
Spontaneous intracranial hypotension (SIH) is characterized by a severe and disabling headache that is usually orthostatic in nature. Cisternography is a useful diagnostic test for evaluating the presence and location of cerebrospinal fluid (CSF) leakage, and a targeted epidural blood patch (EBP) based on the cisternography findings is a very effective treatment modality for SIH. However, the effects of EBPs are not predictable, making repeat EBPs essential in some cases. The aim of the present study was to find the relationship between the EBP response and cisternographic findings, hypothesizing that the number of required EBPs would increase with an increased number of CSF leakage levels as determined by radionuclide cisternography.
All patients who underwent an EBP and had been discharged with significant improvements in symptoms of SIH during 2006 to 2011 were enrolled. Patients who had no radionuclide cisternographic results were excluded. The demographic variables, number of EBPs, cisternographic findings (location, bilaterality, and number of leakage sites), and preprocedural and postprocedural pain scores were reviewed.
There was no correlation found between the cisternographic findings and the number of EBPs. Only the preprocedural pain scores showed a statistically significant correlation with the number of EBPs.
Our study suggests that the response to the EBP is related to the severity of symptoms but not to the number and locations of cisternographic CSF leakages.
PMID: 25493688

Spontaneous intracranial hypotension syndrome treated with fludrocortisone
Rizk M1, Khatib ME, Yamout B, Hujeily E, Ayoub S, Ayoub C, Skaf G.
A A Case Rep. 2015 Jan 1;4(1):8-11.
Spontaneous intracranial hypotension is a rare syndrome characterized by orthostatic headache not associated with trauma or dural puncture. In most cases, it is caused by a spontaneous spinal cerebrospinal fluid leakage as demonstrated by neuroradiological studies. The standard of care consists of conservative treatment including bed rest, hydration, and administration of caffeine or glucocorticoids. When such conservative therapy fails, an epidural blood patch is recommended. In this report, we describe the treatment of 2 patients with spontaneous intracranial hypotension who failed conservative treatment and went on to have complete and sustained resolution of their symptoms after the administration of oral fludrocortisone.
PMID: 25612272

Treatment of spontaneous intracranial hypotension with intravenous factor xııı administration: initial clinical experience
Nagatani K, Takeuchi S, Wada K, Mori K, Shima K.
Turk Neurosurg. 2015;25(1):69-72.
Coagulation Factor XIII plays an important role in wound healing by stabilizing the fibrin clot. We hypothesized that Factor XIII administration might promote the repair of cerebrospinal fluid leak sites and lead to resolution of the orthostatic headache in patients with spontaneous intracranial hypotension (SIH). The aim of this study was to investigate the efficacy of intravenous Factor XIII administration in SIH patients.
A retrospective review of nine patients (four men, five women; mean age 42.3 yr) with SIH resistant to conservative treatment (bed rest, hydration and analgesics) was performed. All patients had an orthostatic headache. Intravenous administration of Factor XIII (1200 units per day for at least five days) was additionally performed on all patients.
The orthostatic headache completely resolved and never reoccurred in six patients (67%), and partially resolved in two patients (22%). One patient (11%) had no change in headache activity. No complications occurred in any patients treated with Factor XIII.
This study may suggest that intravenous administration of Factor XIII is useful for treating SIH, even if the patients are resistant to conservative treatment.
PMID: 25640548
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