Abstract
Introduction
This study aimed to evaluate the diagnostic imaging findings and treatment results of patients with idiopathic intracranial hypotension (IIH) due to cerebrospinal fluid (CSF) leaks.
Methods
Between February 2009 and April 2012, 26 IIH patients (15 men, median age 49 years) presenting with orthostatic headache (n = 20) and/or with spontaneous subdural effusions or subarachnoid hemorrhage (n = 19) were enrolled. Twenty-three patients underwent a whole spine CT and MRI myelography, starting 45 min after the intrathecal injection of 9 cc of iomeprol (Imeron 300 M) and 1 cc of gadobutrolum (Gadovist). Three patients only underwent MR myelography after intrathecal gadobutrolum injection. Adjacent to the level(s) of the detected CSF leak(s) along the nerve roots, 20 cc of fresh venous blood with 0.5 cc Gadovist was injected epidurally (blood patch, BP). The distribution of the BP was visualized by MRI the following day. Treatment results were evaluated clinically and by myelography 2 weeks after the application of the BP. Retreatment was offered to patients with persistent symptoms and continued CSF leakage.
Results
CSF leaks were detected at the cervical (n = 12), thoracic (n = 25), or lumbar (n = 21) spine. In 23 patients, more than one spinal segment was affected. One patient refused treatment. BP were applied in one (n = 9) or several (n = 16) levels. Clinical and/or radiological improvement was achieved after one (n = 16), two (n = 5), three (n = 3), or five (n = 1) BPs.
Conclusion
CT and MRI myelography allow the reliable detection of spinal CSF leaks. The targeted and eventually repeated epidural BP procedure is a safe and efficacious treatment.
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References
Schievink WI (2006) Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 295:2286–2296
Ferrante E, Savino A, Sances G, Nappi G (2004) Spontaneous intracranial hypotension syndrome: report of twelve cases. Headache 44:615–622
Mokri B (2003) Headaches caused by decreased IC pressure: diagnosis and management. Curr Opin Neurol 16:319–326
Zada G, Solomon TC, Giannotta SL (2007) A review of ocular manifestations in intracranial hypotension. Neurosurg Focus 23:E8
Sayer FT, Bodelsson M, Larsson EM, Romner B (2006) Spontaneous intracranial hypotension resulting in coma: case report. Neurosurgery 59:E204
Mokri B (1999) Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia—evolution of a concept. Mayo Clin Proc 74:1113–1123
Garcia-Morales I, Porta-Etessam J, Galan L (2001) Recurrent subdural haematomas in a patient with spontaneous intracranial hypotension. Cephalalgia 21:703–705
Forghani R, Farb RI (2008) Diagnosis and temporal evolution of signs of intracranial hypotension on MRI of the brain. Neuroradiology 50:1025–1034
Albayram S, Kilic F, Ozer H, Baghaki S, Kocer N, Islak C (2008) Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. AJNR Am J Neuroradiol 29:116–121
Schick U, Musahl C, Papke K (2010) Diagnostic and treatment of spontaneous intracranial hypotension. Minim Invas Neurosurgery 53:15–20
Moriyama E, Ogawa T, Nishida A, Ishikawa S, Beck H (2004) Quantitative analysis of radioisotope cisternography in the diagnosis of intracranial hypotension. J Neurosurg 101:421–426
Olesen J (2008) The international classification of headache disorders. Headache 48:691–693
Jinkins JR, Rudwan M, Krumina G, Tali ET (2002) Intrathecal gadolinium-enhanced MR cisternography in the evaluation of clinically suspected cerebrospinal fluid rhinorrhea in humans: early experience. Radiology 222:555–559
Tali ET, Ercan N, Krumina G et al (2002) Intrathecal gadolinium (gadopentetate dimeglumine) enhanced magnetic resonance myelography and cisternography: results of a multicenter study. Invest Radiol 37:152–159
Aydin K, Guven K, Sencer S, Jinkins JR, Minareci O (2004) MRI cisternography with gadolinium-containing contrast medium: its role, advantages and limitations in the investigation of rhinorrhoea. Neuroradiology 46:75–80
Luetmer PH, Mokri B (2003) Dynamic CT myelography: a technique for localizing high-flow spinal cerebrospinal fluid leaks. AJNR Am J Neuroradiol 24:1711–1714
Schievink WI, Morreale VM, Atkinson JLD (1998) Surgical treatment of spontaneous spinal cerebrospinal fluid leaks. J Neurosurg 88:243–246
Schievink WI, Maya MM, Moser F, Tourje J, Torbati S (2007) Frequency of spontaneous intracranial hypotension in the emergency department. J Headache Pain 8:325–328
Vanopdenbosch LJ, Dedeken P, Casselman JW, Vlaminck SA (2011) MRI with intrathecal gadolinium to detect a CSF leak: a prospective open-label cohort study. J Neurol Neurosurg Psychiatry 82:456–458
Schievink WI, Maya MM, Louy C, Moser FG, Tourje J (2008) Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol 29:853–856
Schievink WI, Gordon OK, Tourje J (2004) Connective tissue disorders with spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension: a prospective study. Neurosurgery 54:65–70
Kranz PG, Gray L, Taylor JN (2011) CT-guided epidural blood patching of directly observed or potential leak sites for the targeted treatment of spontaneous intracranial hypotension. AJNR Am J Neuroradiol 32:832–838
Vogel TW, Dlouhy BJ, Howard MA (2010) Use of confirmatory imaging studies to illustrate adequate treatment of cerebrospinal fluid leak in spontaneous intracranial hypotension. J Neurosurg 113:955–960
Acknowledgments
The authors are grateful to David Ecklund for language revision of the manuscript. Professor Ulrich Speck is our reliable consultant for all contrast media-related matters.
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We declare that we have no conflict of interest.
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Presented in part at the Annual Meeting of the Deutsche Gesellschaft für Neuroradiologie (DGNR) Cologne 2011.
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Albes, G., Weng, H., Horvath, D. et al. Detection and treatment of spinal CSF leaks in idiopathic intracranial hypotension. Neuroradiology 54, 1367–1373 (2012). https://doi.org/10.1007/s00234-012-1055-3
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DOI: https://doi.org/10.1007/s00234-012-1055-3