Intracranial hypotension

Epidural Blood Patch for the Treatment of Abducens Nerve Palsy due to Spontaneous Intracranial Hypotension -A Case Report-

Authors: Kim YA, Yoon DM, Yoon KB.

Intracranial hypotension is characterized by a postural headache which is relieved in a supine position and worsened in a sitting or standing position. Although less commonly reported than postural headache, sixth nerve palsy has also been observed in intracranial hypotension. The epidural blood patch (EBP) has been performed for postdural puncture headache, but little is known about the proper timing of EBP in the treatment of sixth nerve palsy due to intracranial hypotension. This article reports a case of sixth nerve palsy due to spontaneous intracranial hypotension which was treated by EBP 10 days after the onset of palsy.

Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks Clinical article

Authors: Wouter I. Schievink, M.D.1, Marc S. Schwartz, M.D.1,2, M. Marcel Maya, M.D.3, Franklin G. Moser, M.D., M.M.M.3, and Todd D. Rozen, M.D.4

OBJECT: Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension.

METHODS: Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period.

RESULTS: Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients.

CONCLUSIONS: There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

A case of spontaneous intracranial hypotension: From Ménière-like syndrome to cerebral involvement

Authors: Fontaine N, Charpiot A, Debry C, Gentine A.

INTRODUCTION: Spontaneous intracranial hypotension (SIH) is a rare pathology caused by unexplained and variably localized leakage of cerebrospinal fluid (CSF). The prime symptom is orthostatic headache, although other less specific clinical signs may predominate, and mislead diagnosis.
CASE REPORT: A 47-year-old man presented with Ménière-like symptoms of sudden onset. Secondary orthostatic headache led to the performance of cerebral MRI, which found signs suggestive of intracranial hypotension. A blood-patch was immediately carried out, and was followed by consciousness disorder associated with onset of bilateral subdural hematoma, which required iterative neurosurgical drainage. Myelo-CT confirmed CSF leakage facing the right 12th dorsal nerve root sheath. Radio-guided sealing with biologic glue provided complete regression of all symptoms.
DISCUSSION/CONCLUSION: Auditory signs may predominate in the clinical presentation of SIH. Their orthostatic character is suggestive. The present case is of a rare severe form. The role of neurosurgery in such cases remains to be defined.

Catastrophes caused by neurologic diagnostic procedures

Authors: Arias Gómez M.

Serious complications (catastrophes) resulting from diverse neurological diagnostic procedures can be caused by erroneous indication and omission, as well as by delay and erroneous execution or interpretation. Headache, caused by cerebrospinal fluid (CSF) hypotension, is a frequent complication of lumbar puncture; hematic patch is a therapeutic option for severe cases. The most serious complication is cerebral herniation and, for its prevention, computed tomography (CT) or cerebral magnetic resonance imaging (MRI) must always be performed before lumbar puncture: a lesion with evident mass effect is a contraindication. Some cases of minor subarachnoid hemorrhages can produce sentinel headache: when the findings of CT scans are normal, lumbar puncture must be performed for diagnosis and prevention of a catastrophic recurrence. Edrophonium testing can be complicated with bradycardia and/or asystole. The lack of indication of this procedure is a cause of under-diagnosis of myasthenia gravis, especially in older people. Electromyography produces few complications (rare cases of paraspinal hematomas and pneumothorax). Ultrasound, CT angiography and MR angiography examinations have decreased the indications for cerebral angiography, whose main complications -in addition to contrast reactions, hemorrhage and infection at the injection site- are neurological deficits caused by vascular dissection or atheromatous embolus. Video-electroencephalogram (EEG) recording with medication suppression can be used in the presurgical evaluation of epilepsy, which can precipitate repeated seizures with the risk of injuries and status epilepticus. The possible complications of studies performed with invasive electrodes are infections and intracranial hemorrhages. Cerebral biopsy is indicated when treatable disease is suspected but the therapeutic options (radiotherapy, chemotherapy) have potential serious adverse effects. Furthermore, cerebral biopsy can aggravate previous neurological deficits or produce new deficits. Genetic testing is not indicated in healthy children when an untreatable disease is suspected. In adults, genetic testing is appropriate in selected cases, but detailed previous information should be gathered and the possibility of triggering serious emotional reactions should always be considered.

Intracranial hypotension headache after uncomplicated caudal epidural injection

Authors: Thomas R, Thanthulage S.

A caudal epidural injection was performed on a middle-aged woman for pain in her right foot. Although the procedure was uncomplicated and a good epidurogram was obtained, the patient went on to develop an orthostatic headache with generalised weakness and syncopal episodes that were treated successfully by epidural blood patching. We describe the aetiology, presentation and treatment of spontaneous intracranial hypotension and review the similarities with our patient's clinical presentation. We hypothesise as to how our intervention may have resulted in a dural tear.

Spontaneous intracranial hypotension with cerebrospinal fluid leakage at 2 sites treated by epidural blood patch

Authors: Liu CH, Lai SC, Lin CS, Hung HY, Chen MT.

Purpose: Spontaneous intracranial hypotension (SIH) is a relatively uncommon cause of headache, which usually presents as orthostatic cranial pain and is relieved by recumbency. The precise cause of spontaneous spinal cerebrospinal fluid leakage related SIH remains unknown. Case Report: We report the case of a 32-year-old man who presented with an orthostatic headache. Brain magnetic resonance imaging (MRI) revealed typical pachymeningeal enhancement. Radionuclide cisternography revealed leakages in the cervicothoracic and upper cervical areas. The patient was successfully treated by lumbar epidural blood patch (EBP). Conclusion: The diagnosis of SIH involves the assessment of the characteristic clinical presentations and non-invesive neuroimaging studies. The latest diagnostic criteria with more broadened spectrum due to variable manifestations are discussed. EBP is an effective treatment for SIH if conservative management fails.

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