Abstracts 2018

This is a collection of selected publication abstracts about spinal CSF leak / intracranial hypotension from 2018.
This page will be updated periodically.
* Abstract links are included. (click on the PMID number)
* Note that links to full-text are provided for open access papers (line below PMID).

Cervical Foraminal Epidural Blood Patch for the Targeted Treatment of Refractory Cerebrospinal Fluid Leakage From a Dural Sleeve.
Tontisirin N, Benjhawaleemas P, Nimmaanrat S, Sathirapanya P, Laohawiriyakamol T, Tran Q, Finlayson RJ.
Reg Anesth Pain Med. 2018 Feb;43(2):205-210. doi: 10.1097/AAP.0000000000000696.
Epidural blood patches (EBPs) are routinely used to treat symptoms (eg, headaches) associated with spontaneous intracranial hypotension. Although cerebrospinal fluid leakage commonly involves the periforaminal areas of the cervical or thoracic spine, EBPs have been historically performed at the lumbar level. Recent evidence suggests that targeting the causative spinal segment may provide greater clinical benefits. While previous reports have targeted foraminal leaks with segmental thoracic or cervical injections, we present a case report detailing the novel use of a navigable epidural catheter to perform a selective EBP at the C7/T1 foramen.
PMID: 29140961
DOI: 10.1097/AAP.0000000000000696

Magnetic Resonance Imaging of Intracranial Hypotension: Diagnostic Value of Combined Qualitative Signs and Quantitative Metrics.
Aslan K, Gunbey HP, Tomak L, Ozmen Z, Incesu L.
J Comput Assist Tomogr. 2018 Jan/Feb;42(1):92-99. doi: 10.1097/RCT.0000000000000646.
The aim of this study was to investigate whether the use of combination quantitative metrics (mamillopontine distance [MPD], pontomesencephalic angle, and mesencephalon anterior-posterior/medial-lateral diameter ratios) with qualitative signs (dural enhancement, subdural collections/hematoma, venous engorgement, pituitary gland enlargements, and tonsillar herniations) provides a more accurate diagnosis of intracranial hypotension (IH).
The quantitative metrics and qualitative signs of 34 patients and 34 control subjects were assessed by 2 independent observers. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic performance of quantitative metrics and qualitative signs, and for the diagnosis of IH, optimum cutoff values of quantitative metrics were found with ROC analysis. Combined ROC curve was measured for the quantitative metrics, and qualitative signs combinations in determining diagnostic accuracy and sensitivity, specificity, and positive and negative predictive values were found, and the best model combination was formed.
Whereas MPD and pontomesencephalic angle were significantly lower in patients with IH when compared with the control group (P < 0.001), mesencephalon anterior-posterior/medial-lateral diameter ratio was significantly higher (P < 0.001). For qualitative signs, the highest individual distinctive power was dural enhancement with area under the ROC curve (AUC) of 0.838. For quantitative metrics, the highest individual distinctive power was MPD with AUC of 0.947. The best accuracy in the diagnosis of IH was obtained by combination of dural enhancement, venous engorgement, and MPD with an AUC of 1.00. CONCLUSIONS: This study showed that the combined use of dural enhancement, venous engorgement, and MPD had diagnostic accuracy of 100 % for the diagnosis of IH. Therefore, a more accurate IH diagnosis can be provided with combination of quantitative metrics with qualitative signs.
PMID: 28708719
DOI: 10.1097/RCT.0000000000000646

Prevalence of hyperdense paraspinal vein sign in patients with spontaneous intracranial hypotension without dural CSF leak on standard CT myelography.
Clark MS, Diehn FE, Verdoorn JT, Lehman VT, Liebo GB, Morris JM, Thielen KR, Wald JT, Kumar N, Luetmer PH.
Diagn Interv Radiol. 2018 Jan-Feb;24(1):54-59 doi: 10.5152/dir.2017.17220.
A recently identified and treatable cause of spontaneous intracranial hypotension (SIH) is cerebrospinal fluid (CSF)-venous fistula, and a recently described computed tomography myelogram (CTM) finding highly compatible with but not diagnostic of this entity is the hyperdense paraspinal vein sign. We aimed to retrospectively measure the prevalence of the hyperdense paraspinal vein sign on CTMs in SIH patients without dural CSF leak, in comparison with control groups.
Three CTM groups were identified: 1) SIH study group, which included dural CSF leak-negative standard CTMs performed for SIH, with early and delayed imaging; 2) Early control CTMs, which were performed for indications other than SIH, with imaging shortly after intrathecal contrast administration; 3) Delayed control CTMs, which included delayed imaging. CTMs were retrospectively reviewed for the hyperdense paraspinal vein sign by experienced neuroradiologists, blinded to the group assignment. All CTMs deemed by a single reader to be positive for the hyperdense paraspinal vein sign were independently reviewed by two additional neuroradiologists; findings were considered positive only if consensus was present among all three readers. For positive cases, noncontrast CTs and prior CTMs, if available, were reviewed for the presence of the sign.
Seven of 101 (7%) SIH patients had contrast in a spinal/paraspinal vein consistent with the hyperdense paraspinal vein sign; no patient in either control group (total n=54) demonstrated the hyperdense paraspinal vein sign (P = 0.0463). The finding occurred only at thoracic levels. Each patient had a single level of involvement. Six (86%) occurred on the right. Four occurred in female patients (57%). The sign was seen on early images in 3 of 7 cases (43%) and on both early and delayed images in 4 of 7 cases (57%). In 2 of 7 patients (29%), a noncontrast CT covering the relevant location was available and negative for the sign. A prior CTM was available in 2 of 7 patients (29%), and in both cases the hyperdense paraspinal vein sign was also evident.
The prevalence of the hyperdense paraspinal vein sign in SIH patients with dural CSF leak-negative standard CTM was 7%. As the sign was not seen in control groups, this sign is highly compatible with the presence of CSF-venous fistula. Since the CTMs were not specifically dedicated to identifying hyperdense paraspinal veins (i.e., they were not dynamic and were not preceded by digital subtraction myelography), the true prevalence of the sign may be higher. Radiologists should scrutinize conventional CTMs for this sign, especially in patients in whom a traditional dural CSF leak is not identified.
PMID: 29217497
DOI: 10.5152/dir.2017.17220
Full text: http://www.dirjournal.org/eng/makale/1753/62/Full-Text

Ossified ligamentum flavum of the thoracic spine presenting as spontaneous intracranial hypotension: case report.
Turel MK, Kerolus MG, O’Toole JE.
J Neurosurg Spine. 2018 Jan 26:1-5. doi: 10.3171/2017.8.SPINE17513. [Epub ahead of print]
Ossification of the ligament flavum in the thoracic spine is an uncommon radiological finding in the Western population but can present with back pain, varying degrees of myelopathy, and even paraplegia on occasion. The authors here present the case of a 50-year-old woman with a history of progressive back pain and symptoms of spontaneous intracranial hypotension who was found to have an ossified ligamentum flavum of the thoracic spine resulting in a dural erosion cerebrospinal fluid leak. Surgery involved removal of the ossified ligament flavum at T10-11, facetectomy, ligation of the nerve root, and primary closure of the dura, which resulted in complete resolution of the patient’s symptoms. Radiological, clinical, and intraoperative findings are discussed to assist surgeons with an accurate diagnosis and treatment in the setting of this unusual presentation.
PMID: 29372863
DOI: 10.3171/2017.8.SPINE17513

Disc herniation, occult on preoperative imaging but visualized microsurgically, as the cause of idiopathic thoracic spinal cord herniation.
Ulrich CT, Fung C, Piechowiak E, Gralla J, Raabe A, Beck J.
Acta Neurochir (Wien). 2018 Jan 19. doi: 10.1007/s00701-018-3466-3. [Epub ahead of print]
Idiopathic spinal cord herniation (ISCH) through an anterior dural defect is rare and the cause is uncertain. Recently, through interpreting imaging studies, disc herniation was proposed to be a major cause for ISCH. We describe the case of a 50-year-old woman with progressive myelopathy who was diagnosed with a thoracic spinal cord herniation. Microsurgical exploration revealed an anterior vertical dural defect and a small concomitant disc herniation, occult on the preoperative imaging, which caused the dural defect and led to ISCH. This intraoperative finding corroborates the emerging notion that disc herniation is the underlying cause of ISCH.
PMID: 29350292
DOI: 10.1007/s00701-018-3466-3

Intracranial hypotension mimicking chronic progressive external ophthalmoplegia.
Vahdani K, McVeigh K, Harrison R, Williams M, Garrott H.
Orbit. 2018 Jan 4:1-4. doi: 10.1080/01676830.2017.1423346. [Epub ahead of print]
Intracranial hypotension (ICH) is characterized by low cerebrospinal fluid pressure, postural headaches, and diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI). A variety of ophthalmoparetic manifestations have been reported in the context of the ICH. The authors describe an unusual case of a 64-year-old woman who presented with rapid onset of headaches, bilateral upper-lid ptosis, and blurring of vision within 4 days after sustaining a trivial head injury. She was noted to have bilateral symmetrical ophthalmoplegia and ptosis-simulating chronic progressive external ophthalmoplegia. MRI revealed characteristic features of ICH. Subsequent autologous epidural patch therapy led to resolution of the headache and imaging findings; however, her ptosis and motility disorder persisted. Despite existing therapeutic measures for ICH, irreversible cranial nerve damage may ensue due to significant cerebral decent or ischemic injury.
PMID: 29300676
DOI: 10.1080/01676830.2017.1423346

Spontaneous Intracranial Hypotension Induced Headaches and Onabotulinum Toxin A: A Case Report.
Chan TLH, Becker WJ, Hu WY, Amoozegar F.
Can J Neurol Sci. 2018 Jan;45(1):111-113. doi: 10.1017/cjn.2017.257. Epub 2017 Nov 6.
PMID: 29103382
DOI: 10.1017/cjn.2017.257