Abstract
BackgroundSpinal cerebrospinal fluid (CSF) leak can lead to intracranial hypotension and is an important differential diagnosis to consider in patients with sudden-onset chronic daily headaches. Pars interarticularis (PI) fracture is a potential rare cause of suspected spinal CSF leak.MethodsThis is a retrospective case series of 6 patients with suspected spinal CSF leak evaluated between January 2016 and September 2019. All patients received a magnetic resonance imaging (MRI) of the brain with and without gadolinium, MRI whole spine and full spine computed tomography (CT) myelogram. Targeted epidural patches with fibrin sealant were performed. Treatment response at return visit (3 months post-patch) was documented.ResultsSix patients (4 females, 2 males) were diagnosed with a suspected spinal CSF leak and PI fracture. Mean age at the time of headache onset was 39 years old, and a range from 32 to 50 years old. Mean time to targeted epidural patches with fibrin sealant was 4.5 years. All 6 patients had PI fractures identified on CT myelogram and received targeted epidural patches with fibrin sealant at the site of the PI fracture. All patients had significant improvement in their headache intensity.ConclusionOur study highlights: 1) the importance of PI fracture as a possible culprit of suspected spinal CSF leak in patients with intracranial hypotension; 2) the added benefit of CT imaging for detecting bony abnormalities such as fractures in patients with intracranial hypotension; and 3) the successful treatment of suspected spinal CSF leak when targeting the fracture site.
Highlights
Spinal cerebrospinal fluid (CSF) leak can lead to intracranial hypotension and is an important differential diagnosis to consider in patients with sudden onset chronic daily headaches
All 6 patients had an improvement (Greater than 50% reduction) in their headache intensity at their return visit (3 months post-patch) documented based on a pain intensity scale from 0 to 10, 10 being the most severe after treatment targeted at the Pars interarticularis (PI) fracture site (Table 3)
Our study highlights: 1) the importance of PI fracture as a possible culprit of suspected spinal CSF leak in patients with intracranial hypotension; 2) the added benefit of computed tomography (CT) imaging for detecting bony abnormalities such as fractures in patients with intracranial hypotension; and 3) the successful treatment of suspected spinal CSF leak when targeting the fracture site
Summary
Spinal cerebrospinal fluid (CSF) leak can lead to intracranial hypotension and is an important differential diagnosis to consider in patients with sudden-onset chronic daily headaches. In addition to orthostatic headache, patients with spontaneous intracranial hypotension (SIH) can experience a broad clinical spectrum of symptoms, including cochleovestibular dysfunction [16, 17], cranial nerve palsies, visual blurring, upper limb symptoms, encephalopathy, autonomic dysfunction, and cognitive dysfunction [18,19,20] This is presumptively due to sagging of the brain causing significant traction, distortion or compression of anchoring and supporting structures [21]. Several imaging modalities have been utilized to aid in the diagnosis of spinal CSF leak including magnetic resonance
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