Treatment Of Intracranial Hypotension Research Articles

Interrelation Between Cerebrospinal Fluid Pressure, Intracranial Morphology and Venous Hemodynamics Studied by 4D Flow MRI.

To quantify the effects of CSF pressure alterations on intracranial venous morphology and hemodynamics in idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH) and assess reversibility when the underlying cause is resolved. We prospectively examined venous volume, intracranial venous blood flow and velocity, including optic nerve sheath diameter (ONSD) as anoninvasive surrogate of CSF pressure changes in 11 patients with IIH, 11 age-matched and sex-matched healthy controls and 9 SIH patients, before and after neurosurgical closure of spinal dural leaks. We applied multiparametric MRI including 4D flow MRI, time-of-flight (TOF) and T2-weighted half-Fourier acquisition single-shot turbo-spin echo (HASTE). Sinus volume overlapped between groups at baseline but decreased after treatment of intracranial hypotension (p = 0.067) along with asignificant increase of ONSD (p = 0.003). Blood flow in the middle and dorsal superior sagittal sinus was remarkably lower in patients with higher CSF pressure (i.e., IIH versus controls and SIH after CSF leak closure) but blood flow velocity was comparable cross-sectionally between groups and longitudinally in SIH. We were able to demonstrate the interaction of CSF pressure, venous volumetry, venous hemodynamics and ONSD using multiparametric brain MRI. Closure of CSF leaks in SIH patients resulted in symptoms suggestive of increased intracranial pressure and caused asubsequent decrease of intracranial venous volume and of blood flow within the superior sagittal sinus while ONSD increased. In contrast, blood flow parameters from 4D flow MRI did not discriminate IIH, SIH and controls as hemodynamics at baseline overlapped at most vessel cross-sections.

Management of Refractory Intracranial Hypotension Using Percutaneous Fibrin Sealant Patch – A Case Series and Review of the Literature

Background: Intracranial hypotension (IH) among patients with persistent cerebrospinal fluid (CSF) leakage remains a challenging problem. The majority of these cases resolve spontaneously with conservative measures. The customary treatment for IH is epidural blood patch (EBP). In some cases, CSF leaks can persist for months or even years despite multiple trials of EBP. To date, there are only a limited number of published studies documenting the percutaneous injection of fibrin sealant for treatment of IH refractory to conservative measures and EBP. Objective: Our objective was to perform a literature review and retrospective case series regarding patients who underwent percutaneous injection of fibrin sealant for treatment of refractory IH at our institution. Study Design: This case series used a singlecentered retrospective observational study design and literature review. Setting: Patients in this case series were treated at a community-based tertiary care medical center. Methods: Five consecutive patients with the diagnosis of IH refractory to conservative measures and EBP who underwent percutaneous patching with fibrin sealant were identified at our institution between January 1, 2000 and January 1, 2016. A retrospective chart review was performed and data including demographics, characteristics, interventions, clinical outcomes, and complications were collected. A critical review of the current literature regarding the percutaneous use of fibrin sealant for treatment of IH was conducted. Results: Four of the 5 patients (80%) experienced no further symptoms of IH and no adverse events were noted. One patient (20%) ultimately required surgical duroplasty. Review of the current literature showed a total of 2 prospective case series, 4 retrospective case series, and 11 case reports. Our present case series and literature review demonstrated that fibrin sealants were well-tolerated by most patients and associated with low incidences of complications and recurrence. Limitations: This study is limited by the small retrospective case series of 5 patients. Conclusions: Percutaneous injection of fibrin sealant may be considered in refractory cases of IH when repeated trials of EBP have persistently failed. It appears to be a highly effective, safe, and easy-touse alternative therapy for patients with refractory IH in an ambulatory setting. Our review of the literature revealed only studies with low quality of evidence, including case series and case reports. There is a substantial need for high-quality studies and clinical evidence to corroborate the efficacy and safety of this percutaneous technique. However, this ideal is very challenging because of the relative rarity and heterogeneous etiologies of cases. Keywords: Fibrin sealant, intracranial hypotension, CSF leak, epidural blood patch, orthostatic headache, refractory, quality of life, percutaneous

Cerebral Venous Thrombosis in Spontaneous Intracranial Hypotension: A Report on 4 Cases and a Review of the Literature

Spontaneous intracranial hypotension is a risk factor for cerebral venous thrombosis. The occurrence of cerebral venous thrombosis in patients with spontaneous intracranial hypotension raises difficult practical questions regarding the management of the 2 conditions. We reviewed our experience and the relevant literature to evaluate these related questions. We retrospectively studied the medical records and imaging studies of patients with spontaneous intracranial hypotension at a tertiary center from January 2007 through January 2017. The main search strategy was a literature review of journal articles in PubMed (1966 to January 2017). Among 374 patients with spontaneous intracranial hypotension, 4 were also diagnosed with cerebral venous thrombosis. A literature review yielded an additional 31 cases, including 21 men and 14 women with a mean age of 40.6 years. Of the 35 patients, 8 (22.8%) patients received anticoagulation therapy and epidural blood patch. Nineteen (54.3%) patients were given anticoagulant only. Seven (20%) patients were treated with epidural blood patch only. One (2.9%) patient did not receive epidural blood patch or anticoagulation therapy. There is no difference in terms of age, sex, diagnosis interval, association with other complications, and prognosis between the first 3 groups. Of the 19 patients who received anticoagulation therapy, 4 patients (21.1%) had intracranial hemorrhage or hematoma enlargement after anticoagulation, and one of these 4 patients died following further intracranial hemorrhage. Of the 8 patients who received both anticoagulation and epidural blood patch, 1 patient (12.5%, P=0.528) developed subdural hematoma after anticoagulation. Of the 5 cases had intracranial hemorrhage aggravation after anticoagulation, 4 were subdural hematoma occurrence or enlargement. Cerebral venous thrombosis is a rare but important complication of spontaneous intracranial hypotension. The primary focus of treatment should be the treatment of intracranial hypotension. It could be possible that anticoagulation might increase the risk of intracranial hemorrhage in patients with spontaneous intracranial hypotension, although a firm conclusion could not be drawn based on the limited number of patients currently available. The use of anticoagulation therapy should be prudent and should be monitored carefully if initiated.

Changes in Spinal MRI Findings for Epidural Fluid Collection in the Treatment of Intracranial Hypotension

We have experienced 30 cases of intracranial hypotension in the last three years. Spinal MRI was performed in all cases, and 27 patients demonstrated epidural fluid collection(EFC). Of these 30 patients, 6 were treated conservatively with bed rest and hydration, and 24 were treated with epidural blood patch(EBP). Twenty-two patients were cured, 4 were improved significantly, and 4 were improved partially. We examined spinal MR images of 22 patients after 3 months of treatment. The EFC wasn't visible in 11 cases;however, residual EFC was found in the 11 remaining cases. The patients without EFC were cured. Of the 11 patients with residual EFC, 4 patients were cured, 4 were improved significantly, and 3 showed partial improvement. Furthermore, in subsequent spinal MRI of 7 patients, EFC wasn't visible in 2 patients;however the patients continued to experience moderate orthostatic headache. Therefore, while EFC is closely associated with spinal CSF leakage, the presence of CSF leakage doesn't necessitate the observation of EFC by current MRI. In post-treatment spinal MRI, we sometimes observed residual EFC in the ventro-lateral area of the spinal dural sac, especially in the thoracic region;hence, we speculated that CSF leakage may occur in the ventro-lateral aspect of spinal dural sac in many cases of intracranial hypotension. Moreover, in these cases, subsequent treatment with EBP cannot assure the delivery of autologous blood to the residual EFC. Therefore, we considered that the residual EFC in the ventro-lateral epidural space is often separated from its dorsal part.

Alternative treatment of intracranial hypotension presenting as postdural puncture headaches using epidural fibrin glue patches: two case reports

Introduction: Intracranial hypotension is a neurologic syndrome characterized by orthostatic headaches and, radiographically, by dural thickening and enhancement as well as subdural collections. Several of etiologies exist, including surgical dural violations, lumbar puncture, or spontaneous cerebrospinal fluid leak. Current management includes conservative management consisting of bed rest, caffeine, and hydration. When conservative management fails, open surgical or percutaneous options are considered. Currently, the gold standard in percutaneous management of intracranial hypotension involves the epidural injection of autologous blood. Recently, some therapies for intracranial hypotension have employed the use of epidural fibrin glue. Case Presentation: Two cases of patients with persistent postdural puncture headaches are presented. Epidural fibrin glue injection alleviated the orthostatic headaches of two patients with intracranial hypotension. Conclusion: Although consideration must be afforded for the potential risks of viral transmission and aseptic meningitis, the utilization of epidural fibrin glue injection as an alternative or adjunct to the epidural blood patch in the treatment of intracranial hypotension should be further investigated.

Intracranial hypotension masquerading as nonconvulsive status epilepticus

Intracranial hypotension (IH) has been a known entity in neurocritical care since 1938. Even though many cases are spontaneous, the incidence of intracranial hypotension in the neurocritical care setting is increasing by virtue of the increased number of neurosurgical interventions. Whether spontaneous or secondary in etiology, diagnosis of IH usually requires the presence of orthostatic symptoms, including headaches and nausea with low opening CSF pressure. However, typical clinical features in the appropriate clinical context and imaging, even with normal CSF pressure, can indicate IH. In the neurocritical care setting, challenges for accurate semiology include altered sensorium and reduced levels of responsiveness for which many etiologies may exist, including metabolic dysfunction, traumatic brain injury, IH, or nonconvulsive status epilepticus (NCSE). The authors describe 3 patients whose clinical picture and electroencephalography (EEG) findings initially suggested NCSE but who did not respond to treatment with antiepileptic drugs alone. Neuroimaging suggested IH, and subsequent treatment of IH successfully improved the patient's clinical status. To the authors' knowledge this paper is the first in the literature that reports a correlation of IH with electrographic findings similar to NCSE as cause and effect. The authors' hypothesis is that thalamocortical dysfunction causes EEG findings that appear to be similar to those in NCSE but that these conditions do not coexist. The EEG activity is not epileptogenic, and IH results in blocking network pathways producing thalamocortical dysfunction. The authors discuss the hypothesis and pathophysiology of these epileptiform changes in relation to IH.

Sonographic Assessment of the Optic Nerve Sheath and Transorbital Monitoring of Treatment Effects in a Patient with Spontaneous Intracranial Hypotension: Case Report

To investigate the potential of the ultrasound-based evaluation of the optic nerve sheath in a patient with spontaneous intracranial hypotension due to cervical cerebrospinal fluid (CSF) leakage. Repeated measurements of the optic nerve sheath diameter (ONSD) using B-mode sonography were performed before treatment initiation, during medical treatment, and during a course of repeated placement of epidural blood patches. On admission, transorbital sonography revealed a decreased ONSD of 4.1 mm on the right and 4.3 mm on the left side. After 8 months of treatment with caffeine and computed tomography-guided epidural blood patches a gradual distension of the ONSD into the normal range was bilaterally observed (right: 5.2 mm; left: 5.3 mm). The ultrasound-based evaluation of the optic nerve sheath may be helpful in detecting CSF hypovolemia and for determination of treatment effects. This report should be seen as a basis for future investigations on the sonographic assessment of the optic nerve sheath in diagnosis and treatment of intracranial hypotension.

Reply to Dr. Takeuchi: PRES after epidural anesthesia

We thank Dr Satoru Takeuchi and his colleagues for their comments [1] about our article on the probable causal association between intracranial hypotension (IH) and posterior reversible encephalopathy syndrome (PRES) [2]. They ask us to further debate the possible role of reversible cerebral vasoconstriction syndrome (RCVS) in the clinical history of our patient. RCVS is a group of disorders characterized by the reversible segmental and the multifocal vasoconstriction of cerebral arteries at angiography and severe “thunderclap” headache with or without focal neurological deficits or seizures [3]. In our patient, RCVS was mainly ruled out because of normal MRA findings. As described by Ducros et al. [4], some patients (only 9% of the cases) even with an initial normal MRA could have a repeated MRA showing vessels narrowing, but we did not suspected RCVS because of the headache clinical features and the neurological signs. In fact, our patient presented a bilateral headache, pressure-like, with a postural component, different from the thunderclap headache, typical of RCVS. It is possible that the mild headache onset was consequent to the epidural anesthesia, but the headache did not change in severity until the patient discharge, some days after the end of anesthesia effect. Moreover, the MR findings were typical of PRES, showing multiple symmetric and bilateral hypertintensities on T2-weighted images in the posterior territories, with high signal on DWI, as well as on ADC maps. It has been described that a post-partum RCVS could cause PRES [5, 6], but we supposed that the demonstrated intra-cranial hypotension (IH), subsequent to the inadvertent dural puncture, was the leading cause of PRES. This hypothesis is mainly supported by the prompt resolution of the neurological symptoms and the radiological alterations of both IH and PRES, only after the treatment of IH with a blood patch. This would be difficult to be expected in case of RCVS. Finally, we know that the association between IH and PRES is only a presumption and that there are some limitations of our single experience and of the proofs provided. We look forward to further contributions that could eventually clarify the relationship between IH and PRES.

CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension

Optimal diagnosis and management of spontaneous intracranial hypotension remains uncertain. CT-guided blood patching has been described but has not been evaluated in larger case series. We sought to evaluate the efficacy of CT-guided blood patching of observed or potential CSF leaks in spontaneous intracranial hypotension. Patients referred for evaluation of spontaneous intracranial hypotension were retrospectively reviewed. Inclusion criteria were findings of intracranial hypotension on pretreatment brain MR imaging, evaluation and treatment with CT-guided myelography and blood patching, and availability of posttreatment brain MR images. Eight patients met inclusion criteria. Imaging findings, treatment details, and clinical outcomes were assessed. Pretreatment imaging findings included dural enhancement, tonsillar ectopia, subdural collections, and syrinx. All findings resolved or significantly improved on posttreatment imaging. Presenting clinical symptoms included positional headache, neck/interscapular/shoulder pain, and tinnitus. Headaches and neck/interscapular/shoulder pain improved in all patients; tinnitus improved in 1 of 2 patients. CSF leak sites were directly visualized in 37% of patients and were targets for patching when seen. When no direct visualization of leaks was seen, irregular spinal nerve root diverticula were targeted as potential leak sites. The average number of blood patching sessions was 3 (range, 1-6) and the average number of individual sites patched per session was 5 (range, 1-10). Our results suggest that CT-guided blood patching targeting observed or potential leak sites can be effective in the treatment of intracranial hypotension. Prospective controlled studies are needed to confirm efficacy and compare outcomes with other treatment options.

Intracranial hypotension and PRES: a reply

We thank Dr Hong-Liang Zhang and colleagues for their interest and comments on our article [1] about the probable causal association between intracranial hypotension (IH) and posterior reversible encephalopathy syndrome (PRES). We surely agree that further investigations are required in order to better clarify the relationship between these two entities. We are aware that the association between IH and PRES has not been reported in literature, that we should be cautious about proposing this diagnosis and that this physiopathological correlation is only a presumption. Our hypothesis is supported by the prompt resolution of the neurological symptoms and radiological alterations of both IH and PRES only after the treatment of IH with a blood patch without any other specific therapy used to treat PRES and any other clear cause of PRES. Some of the possible etiologies of PRES were ruled out with clinical examination and laboratory data. They were negative for arterial hypertension, proteinuria, liver function abnormalities, peripheral edema on examination; moreover, none of the drugs used in the peripartum period could be responsible for PRES. About the diagnosis of IH, although lumbar puncture is the gold standard, we considered it dangerous because of the accentuated venous hypertension and consequent brainstem descent. Moreover, imaging revealed not only the presence of pachimeningeal thickening, enhancing after contrast administration, but also, as mentioned, downward displacement of brain and engorgement of venous structures, such as dural sinuses, Galen vein and epidural venous plexi associated with bilateral subdural cerebrospinal fluid collections, signs suggestive of IH. It is correct to note that the Fig. 1a in our article is a T2-weighted image acquired with a fluid attenuated inversion recovery technique. Even considering the limitations of our single experience and of the proofs provided, we look forward with a great interest to other reports that could eventually clarifying the relationship between IH and PRES.

Isolated Cortical Venous Thrombosis Associated With Intracranial Hypotension Syndrome

The association of intracranial hypotension syndrome with cerebral venous thrombosis is rare. We report our experience with isolated cortical venous thrombosis, which developed after unsuccessful epidural anesthesia. Magnetic resonance imaging showed characteristic imaging findings of intracranial hypotension syndrome, such as dural thickening and brain sagging. We also detected right parietal venous hemorrhagic infarction secondary to right-sided cortical venous thrombosis. After the treatment of intracranial hypotension via epidural blood patch, heparin was used to treat cortical venous thrombosis.

Chromium geochemistry in serpentinized ultramafic rocks and serpentine soils from the Franciscan complex of California

<h3>BACKGROUND AND PURPOSE:</h3> Optimal diagnosis and management of spontaneous intracranial hypotension remains uncertain. CT-guided blood patching has been described but has not been evaluated in larger case series. We sought to evaluate the efficacy of CT-guided blood patching of observed or potential CSF leaks in spontaneous intracranial hypotension. <h3>MATERIALS AND METHODS:</h3> Patients referred for evaluation of spontaneous intracranial hypotension were retrospectively reviewed. Inclusion criteria were findings of intracranial hypotension on pretreatment brain MR imaging, evaluation and treatment with CT-guided myelography and blood patching, and availability of posttreatment brain MR images. Eight patients met inclusion criteria. Imaging findings, treatment details, and clinical outcomes were assessed. <h3>RESULTS:</h3> Pretreatment imaging findings included dural enhancement, tonsillar ectopia, subdural collections, and syrinx. All findings resolved or significantly improved on posttreatment imaging. Presenting clinical symptoms included positional headache, neck/interscapular/shoulder pain, and tinnitus. Headaches and neck/interscapular/shoulder pain improved in all patients; tinnitus improved in 1 of 2 patients. CSF leak sites were directly visualized in 37% of patients and were targets for patching when seen. When no direct visualization of leaks was seen, irregular spinal nerve root diverticula were targeted as potential leak sites. The average number of blood patching sessions was 3 (range, 1–6) and the average number of individual sites patched per session was 5 (range, 1–10). <h3>CONCLUSIONS:</h3> Our results suggest that CT-guided blood patching targeting observed or potential leak sites can be effective in the treatment of intracranial hypotension. Prospective controlled studies are needed to confirm efficacy and compare outcomes with other treatment options.