Cerebrospinal Fluid Hypotension Research Articles

Case Report of Compensated Idiopathic Intracranial Hypertension due to Traumatic Cerebrospinal Fluid Fistula

IntroductionDisorders of intracranial pressure, both Intracranial Hypertension (IH) and Cerebrospinal Fluid Hypotension (CSFH), are causes of headache and can impair quality of life and lead to various complications. These conditions can cause symptoms such as transient visual loss, tinnitus, gait and balance disturbances, but positional headache is the main symptom. In this report, we present the case of a patient who was diagnosed with Idiopathic Intracranial Hypertension (IIH) and later developed a change in the pain pattern, caused by traumatic Cerebrospinal Fluid Fistula.ObjectiveTo report the case of a patient diagnosed with Idiopathic Intracranial Hypertension (IIH), who had a good response to medical treatment for several years but experienced worsened headache and a change in pain pattern (becoming orthostatic) following a Traumatic Brain Injury (TBI).ResultsFemale patient, 33 years old, obese, accompanied in an outpatient headache clinic in Joao Pessoa - PB. In 2018, she presented with a progressive holocranial headache that worsened with dorsal decubitus, accompanied by transient visual darkening. She was diagnosed with IIH after a cerebrospinal fluid (CSF) collection and exclusion of other causes. Since then, she has been taking Topiramate and making lifestyle changes, such as regular physical activity, dietary changes, and weight loss, resulting in significant improvement of symptoms for a few years. In January 2023, she suffered a mild TBI (hit her head on a cabinet) and a few days later, she started experiencing intense and almost daily headaches, but different from the previous ones. Now, the pain worsened or appeared in upright position and was accompanied by clear, colorless, odorless, fluid and constant rhinorrhea in the right nostril, ear fullness, nausea, and occasional vomiting. At that time, she stopped the medication and had partial improvement of symptoms.After reporting these events during the follow-up appointment, she underwent investigation with Magnetic Resonance Imaging (MRI) with cerebrospinal fluid flow study, which revealed a frontoethmoidal meningoencephalocele through a bone defect in the cribriform plate. In a joint decision with the Neurosurgery team, it was opted not to correct the fistula and to proceed with a ventriculoperitoneal shunt. She had a great improvement after the procedure, was discharged days later without symptoms.ConclusionTherefore, we report a case of a patient with secondary headache due to IIH that achieved good symptom control for several years. However, after a MTI injury, the headache recurred with a new pattern and was accompanied by new symptoms. She was diagnosed with a Cerebrospinal Fluid Fistula and Meningoencephalocele, and underwent ventriculoperitoneal shunt placement. She showed good progress and response to treatment.

Behavioral Variant Frontotemporal Dementia like Syndrome –Atypical Presentation of Intracranial Hypotension

Spontaneous Intracranial Hypotension (SIH) is an uncommon syndrome which may result from a Cerebrospinal Fluid (CSF) leak. Atypical SIH may present with neurobehavioral symptoms similar to those observed in behavioral variant Frontotemporal Dementia (bvFTD). We present a case of a 55-year-old male with postural headache and behavioral symptoms who was initially diagnosed with bvFTD. On re-evaluation in our clinic, imaging revealed caudal displacement of the midline structures suggestive of Cerebrospinal Fluid (CSF) hypotension. We hypothesized that with unmitigated CSF loss over a long period of time, the patient developed brain sagging clinically resulting in neurobehavioral, frontal lobe dysfunction. After multitude of investigative procedures, a CSF venous fistula originating from a T7 nerve root cyst was found and repaired. Surgical intervention and restoration of CSF volume resulted in resolution of cognitive as well as neurobehavioral symptoms.

Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture

Introduction Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25G or less and 2) greater than 25G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results 141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (P=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (P=0.026). Conclusion 25G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

Spinal pseudomeningocele closure: capsulofascial interposition technique.

The development of a spinal pseudomeningocele is a complication of dural repair or reconstruction that carries significant morbidity for pediatric patients. In addition to cerebrospinal fluid (CSF) hypotension and positional headaches, CSF leaking into the extradural space increases the risk for incisional breakdown, meningitis, and cosmetic deformity. Spinal pseudomeningocele management is challenging, and reported techniques range from local wound revisions/exploration to shunt placement for permanent CSF diversion. At our institution, we have recently implemented a multidisciplinary approach of capsulofascial interposition for the surgical repair of the symptomatic spinal pseudomeningocele with a combined neurosurgery-plastic surgery team. To our knowledge, this technique has not previously been characterized, and we describe the technical aspects of this surgery here. Among 10 patients treated with this technique, none required reoperation or developed infections following pseudomeningocele closure; 2 patients received postoperative transfusions; and 2 patients underwent CSF diversion procedures. We propose that this capsulofascial interposition technique should be employed in the surgical treatment of symptomatic spinal pseudomeningoceles.

Above-The-Hairline Suboccipital Transverse Approach for the Treatment of Chiari I Malformation.

Chiari I malformation is a common pediatric neurosurgical disorder with an established treatment paradigm. Posterior fossa decompression and duraplasty (PFDD) is associated with symptom improvement but it carries postoperative risk, particularly cerebrospinal fluid (CSF) leak and wound complications. In addition, the cosmetic outcomes of PFDD have been overlooked in the literature. To describe a novel approach for PFDD in which the transverse surgical incision is completely hidden above the hairline and to report early outcomes in a prospective patient cohort. Clinical and cosmetic outcomes were recorded for 15 consecutive pediatric patients who underwent PFDD for Chiari I malformation via the above-the-hairline transverse suboccipital approach. The median clinical follow-up time was 6 months (range 1-12 months), and the majority of patients experienced significant improvement of their preoperative symptoms. Three patients (20%) experienced complications associated with surgery, which included injury to the greater occipital nerve, CSF hypotension and subfascial pseudomeningocele, and superficial wound dehiscence that resolved spontaneously with oral antibiotics. Zero patients (0%) returned to the operating room for persistent CSF leak, deep wound infection, or revision decompression. An excellent cosmetic outcome was achieved in 12 patients (80%). No patient had a poor cosmetic outcome. The above-the-hairline transverse suboccipital approach for PFDD in patients with Chiari I malformation offers favorable cosmetic outcomes and fascial closure while permitting adequate decompression.

Caliber and type of needle are associated with the risk of spontaneously reported post-dural punction headache

Introduction
 Post-dural punction headache (PDH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in hypovolemia and CSF hypotension. The risk factors for PDH are not yet fully understood. 
 Objective
 To evaluate the risk of spontaneously reported PDH according to the size and type of spinal tap needle.
 Methods
 A total of 4589 patients undergoing outpatient lumbar puncture were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone the onset of orthostatic headache during the first 7 days after the puncture to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. 
 Needle gauge was classified into two groups: 1) 25G or less and 2) greater than 25G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. 
 Comparisons of the percentages of spontaneous reports of PDH were made using the chi-square test.
 Results
 141 patients (3.07%) reported PHD to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of greater than 25G needles (P=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (P=0.026). 
 Conclusion
 25G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD. 
 Key-words:
 Post-dural punction headache, Spinal Tap, Spinal Tap Needle.

Modern approaches to the diagnosis and treatment of spontaneous intracranial hypotension (a literature review)

The aim of this review is to analyze and summarize the existing evidence regarding the diagnosis and treatment of spontaneous intracranial hypotension. Spontaneous intracranial hypotension occurs due to a decrease in cerebrospinal fluid (CSF) volume as a result of its spontaneous leakage and has a variety of clinical and neuroimaging features, sometimes different from CSF hypotension after a lumbar puncture. Anatomical changes in spontaneous CSF leakage are complex and are often associated with structural disorders of the connective tissue, weakness of certain areas of the dura mater and its diverticulosis. One consequence of decreased CSF volume is brain descent. This leads to traction of pain-sensitive brain structures and, therefore, to headaches that are orthostatic or with some orthostatic features. The methods of choice to identify the site of CSF leak are CT-myelography and radioisotope cisternography. Epidural blood patch is the main treatment in most cases. Conclusions. The study on the most informative and minimally invasive methods to locate the site of CSF leak, conservative and surgical methods of treatment efficacy evaluation depending on the etiological factors of spontaneous intracranial hypotension are extremely important and promising scientific fields requiring further research with the development of personalized approaches considering the individual characteristics of each patient.

Headache and neuroimaging findings in conditions of cerebrospinal fluid (CSF) circulation disorders: in hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome

The authors wish in this narrative minireview show and comment on some neuroimaging findings encountered in patients with conditions of cerebrospinal fluid circulation disorders, such as in the hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome. The MRI of a young woman with a clinical diagnosis of post-dural puncture headache, performed on the fourth postpartum day after cesarean delivery, evolving with headache and diplopia, is shown. Non-contrast-enhanced sagittal T1 magnetic resonance imaging shows that the cerebellar tonsils are at the level of the foramen magnum, therefore still within normal limits, but, despite that, the opening of the cerebral aqueduct in the third ventricle is below the imaginary line connecting the anterior clinoid to the vein of Galen, therefore considered abnormally lower than the expected anatomical position. The axial T1-weighted images with post-contrast fat suppression also show impregnation and thickening of the dura mater. There is also mild engorgement of the cerebral venous sinuses, best demonstrated on T1 with post-contrast fat suppression, which is also identified on post-contrast magnetic resonance angiography, with no signs of venous thrombosis. We conclude that the diagnosis of a patient with intracranial hypotension syndrome can be suspected or confirmed with typical neuroimaging findings.

Traumatic vs Spontaneous Cerebrospinal Fluid Hypotension Headache: Our experience in a series of 137 cases

ObjectivesTo analyze and compare differences between epidemiological and clinical aspects, as well as radiologic findings and treatment, in a series of adult patients with traumatic intracranial hypotension (TIH) and spontaneous intracranial hypotension (SIH) treated at our institution in order to identify predictors of recurrence. BackgroundCerebrospinal fluid hypotension headache (CSF-HH) is often caused by orthostasis and relieved by recumbency. Etiology can be either traumatic or spontaneous. Indirect signs of CSF hypotension are often observed on brain MRI. The most common therapeutic approach is conservative management and, when necessary, the use of an epidural blood patch. MethodsMedical history and brain MRI of adult patients consulting our institution with a diagnosis of CSF-HH between January 2010 and March 2019, were retrospectively reviewed. Clinical criteria as per the International Classification of Headache Disorders, 3rd edition, were applied. Presence of typical MRI findings were assessed by two experienced neuroradiologists, previously informed of patients’ clinical characteristics. Patients were divided into two different groups, namely: Group A: Spontaneous Intracranial Hypotension (SIH) and Group B: Traumatic Intracranial Hypotension (TIH). Recurrence was defined as return of symptoms after one month of remission. In order to find predictors of recurrent intracranial hypotension the patients were divided into three groups: Recurrent Orthostatic headache (ROH); (33 cases; 25%); Non-Recurrent Orthostatic headache (NROH) (84; 61%) and Patients missing follow-up (20; 15%). The latter were excluded from the regression analysis. Results137 patients with CSF-HH were identified: 80 traumatic (54 women, age 33.8 ± 10.4 years) and 57 spontaneous (31 women, age 43.9 ± 15.2 years). Median follow-up was 35 months (range: 8 months–9 years).Compared with TIH, patients with SIH showed lower frequency of orthostatic headache and higher frequency of aural fullness.Also, in patients with SIH, brain MRI showed a higher frequency of pachymeningeal enhancement, ventricular collapse, cisternal obliteration, posterior fossa crowding, brainstem distortion, and a more likely presence of subdural collections.Patients with SIH required an epidural blood patch treatment more often, showed higher recurrence rates, and were more prone to develop subdural hematomas. RecurrenceAs more days elapsed between headache onset and clinical consultation, the presence of spontaneous intracranial hypotension, tinnitus, and thoraco-lumbo-sacral pain were all more common in patients with recurrence.Findings on brain MRI suggesting higher recurrence rates in patients included: ventricular collapse, brainstem distortion, and posterior fossa crowding.Patients treated with invasive therapy (epidural blood patch) presented a higher recurrence rate.In the multivariate regression analysis, the only independent predictor of recurrence after adjusting for age, sex and traumatic vs spontaneous cause of IH, was brainstem distortion diagnosed on MRI (OR 5.13, 95% CI: 1.2-21.7; p = 0.026). ConclusionsSIH and TIH can no longer be likened, since there is considerable variability in clinical presentation, imaging findings, response to treatment and recurrence rates.Anatomical abnormalities underlying SIH leaks are often complex and not simply a disruption of normal structures as encountered in TIH, which could explain why treatment success is poor and recurrence rates remain high.

MON-322 Intrathoracic Meningocele Associated with Neurofibromatosis Type 1: A Case Report

Background: Intrathoracic meningocele is a relatively rare condition, with 60 to 85% of cases being associated with neurofibromatosis type 1. In most cases, meningoceles are small and asymptomatic, and regular follow-up with periodic imaging is recommended without a surgical approach. Most patients become symptomatic between 30 and 50 years of age. Surgical treatment is indicated only when there is an accelerated growth of the meningocele or when the patient presents intense symptoms due to the compression of adjacent structures. Clinical Case: CRSG, 39 years old, female, with non-consanguineous parents. Patient referred to Endocrinology at age 20 by dermatology with the diagnosis of neurofibromatosis made because of the presence of cutaneous neurofibromas and cafe au lait spots. Her father had neurofibromatosis and C-cell hyperplasia diagnosed after total thyroidectomy, and the genetic analysis of RET oncogene was negative. During follow-up, patient evolved with complaints of paresthesia in bilateral upper limbs and mechanical type cervicalgia. In cervical spine MRI, dural ectasia was observed from C4 to T2 levels, with enlargement of the vertebral canal and remodeling of the posterior wall of the vertebral bodies. In parallel, the patient had a diagnosis of primary hyperparathyroidism with serum calcium of 10.7mg/dL(8.6-10.2), vitamin D 29.8ng/dL(>20), PTH 115pg/ml(15-65) and serum phosphorus of 2.2mg/dL(2.8-4.1), and normal renal function. 99mTc-sestamibi scan showed an increased parathyroid gland posterior to the superior pole of the right lobe of the thyroid. After discussion of the case with Neurosurgery and Neuroradiology, it was then hypothesized as a cervical-thoracic meningocele and opted for conservative treatment followed by serial imaging, due to the high surgical risk and little clinical compromise of the patient at the time. Subsequently, she evolved with nausea, intermittent vomiting that made her need daily antiemetic medication. We considered the hypotheses of emesis secondary to hypercalcemia and/or secondary to cerebrospinal fluid hypotension caused by meningocele. Treatment with pamidronate was initiated and the patient and is still under evaluation for probable intracranial cerebrospinal fluid hypotension. Conclusion: Neurological complaints are common during the follow-up of patients with neurofibromatosis and their differential diagnosis is of great importance for adequate therapeutic management. Regarding the main tumor lesion, in addition to the mentioned meningocele in the case, it should be differentiated from neurofibroma, neuroblastoma, ganglioneuroma and cystic hygromas of the posterior mediastinum. Reference: Huang TW, Huang HP, Ye QY, et al. A neurofibromatosis type 1 patient with thoracic encapsulated fluid and intracranial hypotension syndrome: a case report. Neurologist 2011;17:167-171.

Clinical features of hypertrophic pachymeningitis in a center survey.

Hypertrophic pachymeningitis (HP) is characterized by cranial and/or spinal thickening of the dura mater with or without associated inflammation. Neuroimaging studies reveal dura mater thickening and focal or diffuse contrast enhancement. It is described in association with trauma, infections, tumors, autoimmune/inflammatory diseases, and cerebrospinal fluid hypotension syndrome, with some cases remaining idiopathic. A retrospective study was conducted with patients' identification through a key terms search within MRI reports in the period of July 2008 to September 2015. Clinical files, MRI, laboratory, and pathology data were reviewed. Fifty-three patients were identified and 20 were excluded because they did not meet the inclusion criteria. Of the 33 included, 19 were female, with a mean age at symptoms onset of 51.2 ± 17.6years. The most common presenting symptoms were headache and cranial nerves palsy, followed by seizures, delirium, lumbar pain, cognitive decline, motor deficit, and language impairment. In 17 patients, a neoplastic etiology was identified; in eight, inflammatory/autoimmune; in six, infectious; and two were classified as idiopathic. Of the eight patients with inflammatory/autoimmune etiology, four had possible IgG4-related disease (IgG4-RD) and the remaining had granulomatosis with polyangiitis, sarcoidosis, rheumatoid arthritis, and Tolosa-Hunt syndrome. Treatment was directed according to the underlying etiology. In the described series, a female predominance was identified, with symptoms' onset in the 5th decade. Although headache was the most common symptom, clinical presentation was varied, emphasizing the role of MRI in HP diagnosis. The underlying etiologies were diverse, with only a few cases remaining idiopathic, also reflecting the contribution of the recently described IgG4-RD.

An Unusual Case of Reversible Empty Sella.

An empty sella is a relatively common condition, often being an incidental finding at MRI or CT scan. It can develop because of the intrasellar herniation of Cerebro-spinal Fluid (CSF) and arachnoid membrane through an absent or rudimentary diaphragm sellae in concomitance of a sudden and even transient increment of intracranial pressure, leading to a picture in which the pituitary is flattened along the floor of the sella. A young female with headache, nausea, dizziness, diplopia and visual impairment showed an empty sella on MRI and increased CSF pressure at the lumbar puncture. After an initial improvement, there was a progressive worsening of the headache, especially in orthostatic position, with transient relief after bed rest and hydration. At MRI the empty sella was no longer evident, cerebellar tonsils were displaced in the occipital foramen and there was an impregnation of the meninges after contrast medium, a picture of CSF hypotension, probably due to the previously performed lumbar puncture causing a fistula with leak of CSF and consequent disappearance of the empty sella. The patient gradually improved after being submitted to epidural blood patch. The case here reported demonstrates that an empty sella can be a reversible condition in rare cases. Its disappearance can be due to the reduction in intracranial pressure caused by the lumbar puncture itself. The changes in the characteristics of the headache, in particular its worsening in the orthostatic position, should lead to the suspicion of CSF leak through a fistula and consequent intracranial hypotension, a dangerous and sometimes life-threatening condition.

A complication of an epidural blood patch

C. Subdural hematoma. Epidural blood patch (EBP) is generally accepted as an effective and relatively low risk therapeutic option for post dural puncture headache, as well spontaneous spinal cerebrospinal fluid (CSF) leak in patients not responding to conservative management [[1]Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks.Headache. 2013; 53: 1034-1053Crossref PubMed Scopus (196) Google Scholar]. Subdural hematoma (SDH) after EBP is a very rare complication. As in the case described by Verduzco et al., our patients also demonstrated an eight segment spread of the hematoma [[2]Verduzco L.A. Atlas S.W. Riley E.T. Subdural hematoma after an epidural blood patch.Int J Obstet Anesth. 2012; 21: 189-192Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. There are generally three predominant theories for development of SDH after EBP [3Riley C.A. Spiegel J.E. Complications following large–volume epidural blood patches for postdural puncture headache.J Clin Anesth. 2009; 21: 355-359Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 4Devroe S. Van de Velde M. Demaerel P. et al.Spinal subdural hematoma after an epidural blood patch.Int J Obstet Anesth. 2015; 24: 288-289Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. One is that the initial dural puncture with the Tuohy needle created a means of communication between the epidural and subdural spaces. The other is that the Tuohy needle was in the subdural space during the EBP with the blood injected into the subdural space. A third possibility is that both events occurred simultaneously. Intrathecal injection of an EBP has also been reported following accidental dural puncture with MRI demonstrating the intrathecal hematoma [[5]Kalina P. Craigo P. Weingarten T. Intrathecal injection of epidural blood patch.Emerg Radiol. 2004; 11: 56-59Crossref PubMed Scopus (38) Google Scholar]. A complication of an epidural blood patchJournal of Clinical NeuroscienceVol. 31PreviewA 58-year-old woman presented 1 week following an epidural blood patch (EBP) performed due to spontaneous cerebrospinal fluid (CSF) leak (diagnosed by intracranial MRI findings of CSF hypotension obtained for headaches). A spine MRI was performed as part of the continuing work-up to identify the source of the CSF leak (Fig. 1). She was otherwise asymptomatic. Full-Text PDF

Secondary headache in emergency.

Headache is one of the most common causes of access to Emergency Departments (ED). Primary headaches and headaches secondary to benign conditions (e.g headache attributed to acute sinusitis) represent the majority of cases, while secondary life-threatening headaches are less frequent. The primary objective in the ED setting is to decide whether the headache is primary or secondary and recognize serious life-threatening conditions presenting with headache and requiring prompt medical diagnosis and care, such as subarachnoid hemorrhage (SAH), intracerebral hemorrhage, cerebral venous sinus thrombosis (CVST), cervical artery dissection (CAD), brain tumors, pituitary apoplexy, spontaneous intracranial hypotension, or intracranial infections. Careful history taking and physical examination remain the most important part of the assessment of the headache patient[1]. A thorough history should investigate the onset of headache, quality, location and irradiation of pain, associated symptoms experienced before and during the headache, concomitant medical conditions, medication use, recent trauma or interventions. The examination should then target areas identified as abnormal during the headache history; funduscopy evaluation should be performed when symptoms may suggest an increased intracranial pressure; in addition, a complete neurological assessment including level of consciousness, cranial nerve testing, pupillary responses, motor strength and sensorial testing, and signs of meningeal irritation is essential[2]. Based on historical and physical findings “red flags” for secondary headache disorders are sudden onset, onset after 50 years of age, increased frequency, severity or significant change in the usual headache pattern, new onset with an underlying medical condition (such as cancer or immunodepression), concomitant signs of systemic illness (such as fever, neck stiffness, rash), focal neurologic signs or symptoms, papilledema, and head trauma[2]. In headache patients with one or more “red flags” a diagnostic workup is indicated including blood tests, neuroimaging studies, and cerebrospinal fluid (CSF) examinations, which are selected depending on the patient's history and findings. Blood testing and dosage of inflammation indexes (erythrocyte sedimentation rate, C-reactive protein) should be performed in all headache patients especially when an infective or inflammatory condition is suspected. In the ED, non-contrast computed tomography (CT) is the preferred imaging study and is used to rule out hemorrhage, while most patients should perform a magnetic resonance imaging (MRI) brain scan followed by CT/MRI angiography if brain vessel disease is suspected (such as, CAD, aneurysms, and CVST). Lumbar puncture with CSF analysis may help to diagnose SAH, infection, tumor and disorders related to CSF hypertension or hypotension[3, 4]. Treatment and prognosis depend on the etiology of the headache. Prompt recognition and early treatment of secondary headache are essential to avoid some preventable complications.

A Poorly Known Cerebrospinal Fluid Shunt Complication: Miyazaki Syndrome

We studied a poorly known form of cerebrospinal fluid hypotension characterized by cervical myelopathy, a considerable growth in volume of the venous plexus of the cervical spine, and absence of headache. This form was first described by Miyazaki. We reported a case brought to our attention, reviewed the literature, and formulated etiopathogenic theories that might explain all the various clinical aspects of this pathology.

Cerebral venous thrombosis: an unexpected complication from spinal surgery

To provide new insights into the pathophysiology, prevention and diagnosis of cerebral venous thrombosis (CVT) associated with iatrogenic cerebrospinal fluid (CSF) leaks and/or external CSF drainage. Case report and literature review. We describe the case of a 30-year-old woman who developed a CSF fistula after lumbar spinal surgery. The treatment included rest, hydration, caffeine, and continuous lumbar CSF drainage. After closure of the fistula, the patient complained of severe orthostatic headache. Thrombosis involving the superior sagittal sinus, the right transverse sinus, the right sigmoid sinus, and the right jugular vein was diagnosed after neurological deterioration. A few reports have associated CVT with various forms of spinal meningeal injury. However, it has been rarely documented following spinal surgery complicated by accidental durotomy and/or external lumbar CSF drainage. CSF hypovolemia may precipitate CVT in patients having prothrombotic risk factors. Patients who have or had CSF leaks and/or lumbar CSF drains who present with symptoms of intracranial CSF hypotension should remain in the horizontal position to prevent CVT. In that context, the diagnosis of CVT depends on a high degree of suspicion.

Lentiform fork sign in a child with dialysis disequilibrium syndrome: A transient MRI pattern which emphasizes neurologic consequence of metabolic acidosis

A rare but important complication related to otherwise uneventful brain and spine surgery is becoming more recognized and more frequently reported in the medical literature. This has been variably labeled as pseudohypoxic brain swelling or postoperative hypotension-associated venous congestion. This poorly understood condition occurs in the setting of surgical intervention and is thought to be related to cerebrospinal fluid leak or evacuation, decreased intracranial pressure, and subsequent development of deep venous congestion affecting the basal ganglia, thalami, and cerebellum. Clinically, patients may have global neurologic deficit and outcomes range from full recovery to vegetative state or death. The imaging correlate includes atypical edema, infarction, or hemorrhage and can overlap the appearance of diffuse hypoxic injury, for which this condition can be mistaken both clinically and radiologically. Although this deep brain tissue edema can be associated with other signs of cerebrospinal fluid hypotension such as dural thickening, brain sagging, and cerebellar herniation, it can be isolated, making the diagnosis challenging.We present 2 cases of unexpected clinical deterioration occurring in patients with otherwise uncomplicated neurosurgery, 1 with craniotomy and the other with lumbar spine intervention. Both patients exhibit similar appearing edema in the deep gray structures on postoperative magnetic resonance imaging scans. In addition to reviewing the prior literature and imaging findings, we evaluate the imaging findings to determine if there are unique features or signatures that might allow differentiation of PHBS from hypoxic-ischemic encephalopathy.The lentiform rim sign can be helpful for differentiation of pseudohypoxic brain swelling versus hypoxic-ischemic encephalopathy.

Treatment of a Thoracic Dural-Pleural Fistula With a Vascularized Omental Flap

Case report. To report an unusual case of pseudomeningocele with dural-pleural fistula formation and spinal cord herniation after anterior thoracic decompression, as well as a unique surgical method for treating this complication. Thoracic pseudomeningocele with fistula formation is a rare but serious complication of spinal surgery. The negative pressure environment created in the pleural space can complicate management and result in dural-plural fistula formation. We report on the use of a vascularized omental flap to treat this complication after failure of more traditional techniques. A 76-year-old man presented with complaints of myeloradiculopathy, including weakness of lower extremities, with gait and bowel and bladder dysfunction after 2 previous decompressions at the T6-T7 level. Revision surgery was complicated by a dural-plural fistula and spinal cord herniation with neurological deterioration requiring reoperation. Treatment with vascularized omental flap successfully treated the fistula, and the patient had resolution of all symptoms with the exception of some lower extremity neuropathic pain. Postoperative imaging showed excellent decompression of the spinal canal and a small, stable pseudomeningocele without evidence of cerebrospinal fluid hypotension or active dural-pleural fistula. Treatment of thoracic psuedomeningoceles and fistulas can be difficult due to the unique negative intrathoracic pressure environment that complicates closure using traditional methods. Alternative treatment options may be necessary when more traditional techniques fail. Our report highlights one such option, a vascularized omental flap, which was used to successfully treat the patient.

Why don't all individuals who undergo dura mater/arachnoid puncture develop postdural puncture headache?

Why don't all individuals who undergo dura mater/arachnoid puncture develop postdural puncture headache?

Increase in optic nerve sheath diameter induced by epidural blood patch: a preliminary report

Post-dural puncture headache (PDPH) might be related to cerebrospinal fluid hypotension. Studies in brain-injured patients have shown a good relationship between optic nerve sheath diameter (ONSD) measured by ocular sonography and invasively measured intracranial pressure (ICP). The aim of this study was to evaluate changes in ONSD after lumbar epidural blood patch (EBP). Consecutive subjects receiving an EBP for PDPH were included. ONSD and pain measurements were performed before (T(0)), 10 min (M(10)), 2 h (H(2)), and 20 h (H(20)) after the EBP. Ten subjects were included. ONSD [median (inter-quartile range)] increased with time after EBP, from 4.8 mm (4.5-5.1) at T(0) to 5.2 mm (4.9-5.7) at M(10) (P=0.005 vs T(0)), 5.5 mm (5.1-6.0) at H(2) (P=0.007 vs T(0)), and 5.8 mm (5.2-6.3) at H(20) (P=0.02 vs T(0)). EBP was clinically successful in nine of 10 subjects. In subjects in whom EBP was successful, ONSD significantly increased at M(10) and T(2) compared with T(0) (P=0.004 and 0.008, respectively) but did not reach statistical significance at H(20) (P=0.06). In the subject in whom EBP failed, a small increase in ONSD was observed over time. In this preliminary report, EBP was followed by ONSD enlargement in subjects with successful EBP, but not in the subject with EBP failure. Since ONSD is a surrogate marker of ICP, this suggests that a sustained increase in ICP is associated with successful EBP.