The Full Wiki

Intracranial hypotension: Wikis

Advertisements

Note: Many of our articles have direct quotes from sources you can cite, within the Wikipedia article! This article doesn't yet, but we're working on it! See more info or our list of citable articles.

Encyclopedia

(Redirected to Spontaneous cerebrospinal fluid leak article)

From Wikipedia, the free encyclopedia

Spontaneous cerebrospinal fluid leak
Classification and external resources

The spinal meninges
ICD-10 G96.0, G97.0
ICD-9 339.8, 348.4, 349.0, 792.0
MedlinePlus 001068

Spontaneous Cerebrospinal Fluid Leak Syndrome (SCSFLS) is a medical condition in which the cerebrospinal fluid (CSF) held in and around a human brain and spinal cord leaks out of the surrounding protective sac, the dura, for no apparent reason.[1][2] The dura, a tough, inflexible tissue, is the outermost of the three layers of the meninges, the system of membranes surrounding the brain and spinal cord. (The other two meningeal layers are the pia mater and the arachnoid mater).

A spontaneous cerebrospinal fluid leak is one of several types of cerebrospinal fluid leaks and occurs due to the presence of one or more holes in the dura. A spontaneous CSF leak, as opposed to other forms of CSF leaks, arises idiopathically. The loss of CSF due to the leak leads to a decreased volume inside the skull known as intracranial hypotension. SCSFLS is characterized by a severe and disabling headache, dizziness, metallic taste in the mouth, and facial weakness. A CT scan can identify the site of a cerebrospinal fluid leakage. Once identified, the leak can often be repaired by an epidural blood patch, an injection of the patient's own blood at the site of the leak.[3][4]

SCSFLS afflicts 5 out of every 100,000 people. On average, the condition is developed at the age of 42, and women are twice as likely as men to develop the condition. Some people with SCSFLS chronically leak cerebrospinal fluid despite repeated attempts at patching, leading to long-term disability due to pain and nerve damage. SCSFLS was first described by German neurologist Dr. Georg Schaltenbrand in 1938 and by American physician Dr. Henry Woltman of the Mayo Clinic in the 1950s.

Contents

Classification

SCSFLS is classified into two main types, cranial leaks[5] and spinal leaks.[6] Cranial leaks occur in the head. In some cases, CSF can be seen dripping out of the nose[5] or ear.[5] Spinal leaks occur when one or more holes form in the dura along the spinal cord.[6] Both cranial and spinal spontaneous CSF leaks cause neurological symptoms as well as Spontaneous Intracranial Hypotension, diminished volume and pressure of the cranium.[1] For this reason, the SCSFLS is referred to as CSF hypovolemia as opposed to CSF hypotension.[7][8][9][10][11]

Signs and symptoms

Symptoms resulting from nerve impact[12]
Nerve Function Symptoms
vestibulocochlear
(8)
hearing,
balance
hearing and
balance problems
optic
(2)
optic nerve
crossing
blurred vision
facial
(7)
facial nerve facial weakness
and numbness
chorda tympani
(Branch of 7)
taste taste distortion
glossopharyngeal
(9)
taste taste distortion

Symptoms of cerebrospinal fluid leaks include an orthostatic headache[13] in which the pain is worse when the patient is vertical and better when horizontal, severe dizziness and vertigo, facial numbness or weakness, double vision, a metallic taste in the mouth, nausea, and vomiting.[2] Leaking CSF can sometimes be observed exiting through the nose or ear.[14] Orthostatic headaches can be incapacitating [15] and disabling;[16] these symptoms can be sufficiently debilitating to cause those afflicted to be unable to work.[16]

Lack of CSF pressure and volume allows the brain to descend through the foramen magnum, or occipital bone, the large opening at the base of the skull. The lower portion of the brain is believed to stretch or impact one or more nerve complexes, thereby causing a variety of sensory symptoms. Nerve complexes that can be affected and their related symptoms are detailed in the table at right.

Most people who develop SCSFLS feel a sudden onset of a severe and acute headache.[17] The primary place of first complaint to a physician is a hospital emergency room.[17]

Causes

A spontaneous CSF leak is idiopathic; it can arise spontaneously or from an unknown cause. Various scientists and physicians have suggested that this condition may be the result of an underlying connective tissue disorder affecting the spinal dura.[18][19][2][20] Some other studies have proposed that issues with the spinal venous drainage system may cause a CSF leak.[21] According to this theory, dural holes and intracranial hypotension are symptoms caused by low pressure in the epidural space due to outflow to the heart through the inferior vena cava vein.[21]

Pathophysiology

Cerebrospinal fluid (CSF) is produced by the brain by the choroid plexus. The brain floats in CSF and transports nutrients to the brain and spinal cord. CSF is contained by the dura mater.[22] As holes form in the spinal dura mater, CSF leaks out into the surrounding space. The CSF is then absorbed into the spinal epidural venous plexus or soft tissues around the spine.[23]

Diagnosis

Spinal needles used in lumbar puncture and introduction of contrast into the spine
A typical CT scan machine used in the imaging and diagnosis of spinal fluid leak by using non-ionic contrast

Diagnosis of a cerebrospinal fluid leak is performed through a combination of measurement of the CSF pressure and a scan of the spinal column for fluid leaks by use of a computed tomography myelogram (CTM). The opening fluid pressure in the spinal canal is obtained by performing a lumbar puncture, also known as a spinal tap. Once the pressure is measured, radiopaque contrast material is injected into the spinal fluid. The contrast then diffuses out through the dura sac. Once diffused, the contrast leaks through dural holes. This allows for a CTM with fluoroscopy to locate and image any sites of dura rupture via contrast seen outside the dura sac in the imagery.[24]

Magnetic resonance imaging is historically less effective at directly imaging sites of CSF leak. MRI studies may show pachymeningeal enhancement (when the dura mater looks thick and inflammed) and an Arnold-Chiari malformation, but this may not be seen in every case. An Arnold-Chiari malformation occurs when the brain sags and has a downward displacement. This is due to the decreased volume of cerebrospinal fluid in which the brain floats. MRIs can present as completely normal, however, and are not the study of choice.[18] In addition, in 18–46% of cases, the CSF pressure is measured as being in the normal range.[25][7][9][10] An alternate method of locating the site of a CSF leak is to use heavily T2-weighted MR myelography. This has been shown to be effective in identifying the sites of a CSF leak without the need for a CT scan, lumbar puncture, and contrast.[26] This type of MRI is effective at locating fluid collections such as CSF pooling. [26] MRIs done on patients sitting upright compared to those laying down demonstrated no difference in MRI results. [27]

When cranial CSF leak is suspected, due to discharge of fluid from the nose or ear that is potentially CSF, fluid can be collected and then tested with a beta-2 transferrin assay.[28] This test can positively identify if the fluid is cerebrospinal fluid.[28]

Up to 94% of those suffering from SCSFLS are initially misdiagnosed.[29] Incorrect diagnoses include migraines, meningitis, and psychiatric disorders.[29] The average time from onset of symptoms until definitive diagnosis is 13 months.[29]

Treatment

The epidural syringe is filled with autologous blood and injected in the epidural space in order to close holes in the dura mater.

The treatment of choice for this condition is the surgical application of epidural blood patches,[15][30][15][31] which has a 90% success rate in treating dural holes,[32] higher than the conservative treatment of bed rest and hydration.[33] Through the injection of a person's own blood into the area of the hole in the dura, an epidural blood patch uses blood's clotting factors to clot the sites of holes. The volume of autologous blood and number of patch attempts for patients is highly variable.[15] If blood patches alone do not succeed in closing the dural tears, fibrin glue can be added and mixed into the autologous blood patch during a repeat treatment. This has been demonstrated to raise the level of effectiveness of forming a clot and arresting CSF leakage.[6]

In extreme cases of intractable CSF leak, a surgical lumbar drain has been used.[34][35][36] This procedure is believed to decrease spinal CSF volume while increasing intracranial CSF pressure and volume.[34] This procedure restores normal intracranial CSF volume and pressure while promoting the healing of dural tears by lowering the pressure and volume in the dura.[34][36] This procedure has led to positive results leading to relief of symptoms for up to one year.[34][35]

Prognosis

Final outcomes for people with SCSFLS remain poorly studied.[12] Some of those afflicted continue to leak CSF from one or more sites and may suffer from unremitting symptoms for many years.[37] People with chronic SCSFLS may be disabled and unable to work.[16]

Advertisements

Complications

Several complications can occur as a result of SCSFLS, including decreased cranial pressure, brain herniation, infection, blood pressure problems, transient paralysis, and development of a coma.

The primary and most serious complication of SCSFLS is Spontaneous Intracranial Hypotension, where pressure in the brain is severely decreased. [38] This complication leads to the hallmark symptom of severe orthostatic headaches.[38]

People with cranial CSF leaks have a higher chance of developing meningitis than those with spinal CSF leaks.[28] If cranial leaks last more than seven days, the chances of developing meningitis are significantly higher.[28] Those with spinal CSF leaks do not usually develop meningitis due to the mostly aseptic conditions of the spinal dura. [28]

Orthostatic hypotension is another complication which occurs due to autonomic dysfunction when blood pressure drops significantly.[37] The autonomic dysfunction is caused by compression of the brain stem, the part of the brain that controls breathing and circulation.[37]

Arnold-Chiari malformation is a complication of spontaneous CSF leak, where brain tissue moves down through the opening at the base of the skull due to low volume and pressure of CSF

An Arnold-Chiari malformation is a downward displacement of lower parts of the brain through the skull opening that occurs due to a lack of CSF volume and pressure. A further, albeit rare complication of CSF leak is transient quadriplegia due to a sudden and significant loss of CSF. This loss results in hindbrain herniation and causes major compression of the upper cervical spinal cord. The quadriplegia dissipates once the patient lays supine.[39] An extremely rare complication of SCSFLS is third nerve palsy, where the ability to move one's eyes becomes difficult and interrupted due to compression of the third cranial nerve. [40]

There are documented cases of reversible dementia and coma.[25] Coma due to CSF leak has been successfully treated by using blood patches and placing the patient in the Trendelenburg position.[41]

Epidemiology

A 1994 community-based study indicated that two out of every 100,000 people suffered from SCSFLS, while a 2004 emergency room-based study indicated five per 100,000.[42] SCSFLS generally affects the young and middle aged;[34] the average age for onset is 42.3 years, but onset can range from ages 22 to 61.[1] In an 11-year study, from 1992 to 2003, of patients with SCSFLS, women were found to be twice as likely to be affected as men.[43]

Studies have shown that SCSFLS runs in families.[44] It is suspected that genetic similarity in families includes weakness in the dura mater which leads to SCSFLS.[44] Large scale population-based studies have not yet been conducted.[42] While a majority of SCSFLS cases continue to be undiagnosed or misdiagnosed, an actual increase in occurrence is unlikely.[42]

History

Spontaneous CSF leaks have been described by notable physicians and reported in medical journals dating back to the early 1900s. Among them were Georg Schaltenbrand, Henry Woltman of the Mayo Clinic, and a French medical journal.[45][46] German neurologist Dr. Georg Schaltenbrand reported in 1938 and 1953 what he termed "aliquorrhea", a condition marked by very low, unobtainable, or even negative CSF pressures. The symptoms included orthostatic headaches and other features that are now recognized as spontaneous intracranial hypotension. A few decades earlier, the same syndrome had been described in French literature as "hypotension of spinal fluid" and "ventricular collapse". In 1940, Dr Henry Woltman wrote about "headaches associated with decreased intracranial pressure". The full clinical manifestations of intracranial hypotension and CSF leaks were described in several publications reported between the 1960s and early 1990s.[46]

Research and experimental treatments

IV Cosyntropin has been used to treat CSF leaks.[47][48] Cosyntropin is a corticosteroid that causes the brain to produce additional spinal fluid to replace the volume of the lost CSF and alleviate symptoms.[47][48]


In a small study of two patients who suffered from recurrent CSF leaks where repeated blood patches failed to form clots and relieve symptoms, the patients received complete resolution of symptoms with an epidural saline infusion.[49]

See also

References

  1. ^ a b c Maher, CO; Meyer; Mokri (2000). "Surgical treatment of spontaneous spinal cerebrospinal fluid leaks". Neurosurgical focus 9 (1): e7. doi:10.3171/foc.2000.9.1.7. PMID 16859268.  edit
  2. ^ a b c Schievink, WI (2000). "Spontaneous spinal cerebrospinal fluid leaks: a review". Neurosurgical focus 9 (1): e8. doi:10.3171/foc.2000.9.1.8. PMID 16859269.  edit
  3. ^ Ferrante, E.; Wetzl, R.; Savino, A.; Citterio, A.; Protti, A. (2004). "Spontaneous cerebrospinal fluid leak syndrome: report of 18 cases". Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 25 Suppl 3: S293–S295. doi:10.1007/s10072-004-0315-3. PMID 15549566.  edit
  4. ^ Schievink, W.; Maya, M.; Pikul, B.; Louy, C. (2009). "Spontaneous spinal cerebrospinal fluid leaks as the cause of subdural hematomas in elderly patients on anticoagulation". Journal of neurosurgery 112 (2): 295–299. doi:10.3171/2008.10.JNS08428. PMID 19199465.  edit
  5. ^ a b c Lloyd, K. M.; Delgaudio, J. M.; Hudgins, P. A. (2008). "Imaging of Skull Base Cerebrospinal Fluid Leaks in Adults". Radiology 248 (3): 725. doi:10.1148/radiol.2483070362. PMID 18710972.  edit
  6. ^ a b c Gordon, N. (2009). "Spontaneous intracranial hypotension". Developmental Medicine & Child Neurology 51: 932–935. doi:10.1111/j.1469-8749.2009.03514.x.  edit
  7. ^ a b Greenberg, Mark (2006). Handbook of neurosurgery. New York, NY: Thieme Medical Publishers. p. 178. ISBN 0865779090. http://books.google.com/books?id=ExHcxxufG8sC&pg=PA178&dq=Spontaneous+intracranial+hypotension&client=firefox-a&cd=1#v=onepage&q=Spontaneous%20intracranial%20hypotension&f=false. Retrieved 18 December 2009. 
  8. ^ Walsh & Hoyt (2005). Walsh and Hoyt's clinical neuro-ophthalmology, Volume 3. Baltimore, MD: Williams & Wilkins. p. 1303. ISBN 0683060236. http://books.google.com/books?id=ATTlVWi3mvwC&pg=PA1303&dq=Spontaneous+intracranial+hypotension&client=firefox-a&cd=4#v=onepage&q=Spontaneous%20intracranial%20hypotension&f=false. Retrieved 18 December 2009. 
  9. ^ a b Kelley, G (2004). "CSF hypovolemia vs intracranial hypotension in "spontaneous intracranial hypotension syndrome"". Neurology 62 (8): 1453. PMID 15111706.  edit
  10. ^ a b Canas, N; Medeiros, E; Fonseca, AT; Palma-Mira, F (2004). "CSF volume loss in spontaneous intracranial hypotension". Neurology 63 (1): 186–7. PMID 15249640.  edit
  11. ^ Mokri, B (1999). "Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia--evolution of a concept". Mayo Clinic proceedings. Mayo Clinic 74 (11): 1113–23. PMID 10560599.  edit
  12. ^ a b Schievink, W. I. (2008). "Spontaneous spinal cerebrospinal fluid leaks". Cephalalgia : an international journal of headache 28 (12): 1345–1356. doi:10.1111/j.1468-2982.2008.01776.x. PMID 19037970.  edit
  13. ^ Schievink, W.; Palestrant, D.; Maya, M.; Rappard, G. (2009). "Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm". Journal of neurosurgery 110 (3): 521–524. doi:10.3171/2008.9.JNS08670. PMID 19012477.  edit
  14. ^ Hofmann, E.; Behr, R.; Schwager, K. (2009). "Imaging of cerebrospinal fluid leaks". Klinische Neuroradiologie 19 (2): 111–121. doi:10.1007/s00062-009-9008-x. PMID 19636501.  edit
  15. ^ a b c d Mehta, B.; Tarshis, J. (2009). "Repeated large-volume epidural blood patches for the treatment of spontaneous intracranial hypotension". Canadian Journal of Anesthesia/Journal canadien d'anesthésie 56: 609. doi:10.1007/s12630-009-9121-y.  edit
  16. ^ a b c Mea, E.; Chiapparini, L.; Savoiardo, M.; Franzini, A.; Bussone, G.; Leone, M. (2009). "Clinical features and outcomes in spontaneous intracranial hypotension: a survey of 90 consecutive patients". Neurological Sciences 30: 11. doi:10.1007/s10072-009-0060-8.  edit
  17. ^ a b Vaidhyanath, R.; Kenningham, R.; Khan, A.; Messios, N. (2007). "Spontaneous intracranial hypotension: a cause of severe acute headache". Emergency Medicine Journal 24 (10): 739. doi:10.1136/emj.2007.048694. PMID 17901290.  edit
  18. ^ a b Schievink, W. I. (2008). "Spontaneous spinal cerebrospinal fluid leaks". Cephalalgia : an international journal of headache 28 (12): 1345–1356. doi:10.1111/j.1468-2982.2008.01776.x. PMID 19037970.  edit
  19. ^ Mokri, B; Maher, CO; Sencakova, D (2002). "Spontaneous CSF leaks: underlying disorder of connective tissue". Neurology 58 (5): 814–6. PMID 11889250.  edit
  20. ^ Schievink, WI; Gordon; Tourje (2004). "Connective tissue disorders with spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension: a prospective study". Neurosurgery 54 (1): 65–70; discussion 70–1. doi:10.1227/01.NEU.0000097200.18478.7B. PMID 14683542.  edit
  21. ^ a b Franzini, A.; Messina, G.; Nazzi, V.; Mea, E.; Leone, M.; Chiapparini, L.; Broggi, G.; Bussone, G. (2009). "Spontaneous intracranial hypotension syndrome: a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients". Journal of neurosurgery 112 (2): 090710065136044. doi:10.3171/2009.6.JNS09415. PMID 19591547.  edit
  22. ^ Schuenke, Michael; Schumacher, Schulte, Lamperti, Ross, Wesker (2007). Head and neuroanatomy. New York, NY: Thieme. p. 194. ISBN 3131421010. http://books.google.com/books?id=Y0-Rf_m7xj4C&dq=cerebrospinal+fluid&client=firefox-a&source=gbs_navlinks_s. Retrieved 21 December 2009. 
  23. ^ Inamasu, J.; Guiot, B. (2006). "Intracranial hypotension with spinal pathology". The Spine Journal 6 (5): 591. doi:10.1016/j.spinee.2005.12.026. PMID 16934734.  edit
  24. ^ Hofmann, E.; Behr, R.; Schwager, K. (2009). "Imaging of cerebrospinal fluid leaks". Klinische Neuroradiologie 19 (2): 111–121. doi:10.1007/s00062-009-9008-x. PMID 19636501.  edit
  25. ^ a b Sayao, AL; Heran, MK; Chapman, K; Redekop, G; Foti, D (2009). "Intracranial hypotension causing reversible frontotemporal dementia and coma". The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 36 (2): 252–6. PMID 19378725.  edit
  26. ^ a b Wang, Y. -F.; Lirng, J. -F.; Fuh, J. -L.; Hseu, S. -S.; Wang, S. -J. (2009). "Heavily T2-weighted MR myelography vs CT myelography in spontaneous intracranial hypotension". Neurology 73 (22): 1892. doi:10.1212/WNL.0b013e3181c3fd99. PMID 19949036.  edit
  27. ^ Schievink, W. I.; Tourje, J. (2007). "Upright MRI in Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension". Headache: the Journal of Head and Face Pain 47: 1345. doi:10.1111/j.1526-4610.2007.00934.x.  edit
  28. ^ a b c d e Abuabara, A (2007). "Cerebrospinal fluid rhinorrhoea: diagnosis and management". Medicina oral, patologia oral y cirugia bucal 12 (5): E397–400. PMID 17767107.  edit
  29. ^ a b c Schievink, W. I. (2003). "Misdiagnosis of Spontaneous Intracranial Hypotension". Archives of Neurology 60 (12): 1713. doi:10.1001/archneur.60.12.1713. PMID 14676045.  edit
  30. ^ Peng, PW; Farb (2008). "Spontaneous C1-2 CSF leak treated with high cervical epidural blood patch". The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 35 (1): 102–5. PMID 18380287.  edit
  31. ^ Grimaldi, D.; Mea, E.; Chiapparini, L.; Ciceri, E.; Nappini, S.; Savoiardo, M.; Castelli, M.; Cortelli, P. et al. (2004). "Spontaneous low cerebrospinal pressure: a mini review". Neurological Sciences 25: s135. doi:10.1007/s10072-004-0272-x. PMID 15549523.  edit
  32. ^ Kessler, P.; Wulf, H. (2008). "Duraperforation - postpunktioneller Kopfschmerz - Prophylaxe- und Therapiemöglichkeiten". AINS - Anästhesiologie · Intensivmedizin · Notfallmedizin · Schmerztherapie 43: 346. doi:10.1055/s-2008-1079107.  edit
  33. ^ Wang, S. (2008). "Spontaneous Intracranial Hypotension Treated by Epidural Blood Patches". Acta Anaesthesiologica Taiwanica 46: 129–133. doi:10.1016/S1875-4597(08)60007-7.  edit
  34. ^ a b c d e Schievink, W. I. (2009). "A Novel Technique for Treatment of Intractable Spontaneous Intracranial Hypotension: Lumbar Dural Reduction Surgery". Headache: the Journal of Head and Face Pain 49: 1047–1051. doi:10.1111/j.1526-4610.2009.01450.x.  edit
  35. ^ a b Kitchel, SH; Eismont, FJ; Green, BA (1989). "Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the spine". The Journal of bone and joint surgery. American volume 71 (7): 984–7. PMID 2760094.  edit
  36. ^ a b Roosendaal, C. M.; Coppes, M. H.; Vroomen, P. C. A. J. (2009). "The paradox of intracranial hypotension responding well to CSF drainage". European Journal of Neurology 16 (12): e178. doi:10.1111/j.1468-1331.2009.02803.x. PMID 19863649.  edit
  37. ^ a b c Schwedt, TJ; Dodick, DW (2007). "Spontaneous intracranial hypotension". Current pain and headache reports 11 (1): 56–61. doi:10.1007/s11916-007-0023-9. PMID 17214923.  edit
  38. ^ a b Mokri, B (2001). "Spontaneous intracranial hypotension". Current pain and headache reports 5 (3): 284–91. doi:10.1007/s11916-001-0045-7. PMID 11309218.  edit
  39. ^ Schievink, W. I.; Maya, M. M. (2006). "Quadriplegia and cerebellar hemorrhage in spontaneous intracranial hypotension". Neurology 66 (11): 1777. doi:10.1212/01.wnl.0000218210.83855.40. PMID 16769965.  edit
  40. ^ Alonso Cánovas, A; Martínez San Millán, J; Novillo López, ME; Masjuán Vallejo, J (2008). "Third cranial nerve palsy due to intracranial hypotension syndrome". Neurologia (Barcelona, Spain) 23 (7): 462–5. PMID 18726726.  edit
  41. ^ Ferrante, E.; Arpino, I.; Citterio, A.; Savino, A. (2009). "Coma resulting from spontaneous intracranial hypotension treated with the epidural blood patch in the Trendelenburg position pre-medicated with acetazolamide". Clinical Neurology and Neurosurgery 111 (8): 699. doi:10.1016/j.clineuro.2009.06.001. PMID 19577356.  edit
  42. ^ a b c Schievink, W. I. (2006). "Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension". JAMA: the Journal of the American Medical Association 295: 2286. doi:10.1001/jama.295.19.2286.  edit
  43. ^ Ferrante, E.; Wetzl, R.; Savino, A.; Citterio, A.; Protti, A. (2004). "Spontaneous cerebrospinal fluid leak syndrome: report of 18 cases". Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 25 Suppl 3: S293–S295. doi:10.1007/s10072-004-0315-3. PMID 15549566.  edit
  44. ^ a b Larrosa, D; Vázquez, J; Mateo, I; Infante, J (2009). "Familial spontaneous intracranial hypotension". Neurologia (Barcelona, Spain) 24 (7): 485–7. PMID 19921558.  edit
  45. ^ Schaltenbrand, G (1953). "Normal and pathological physiology of the cerebrospinal fluid circulation". Lancet 1 (6765): 805–8. doi:10.1016/S0140-6736(53)91948-5. PMID 13036182.  edit
  46. ^ a b Mokri, B (2000). "Cerebrospinal fluid volume depletion and its emerging clinical/imaging syndromes". Neurosurgical focus 9 (1): e6. doi:10.3171/foc.2000.9.1.6. PMID 16859267.  edit
  47. ^ a b Carter, BL; Pasupuleti (2000). "Use of intravenous cosyntropin in the treatment of postdural puncture headache". Anesthesiology 92 (1): 272–4. doi:10.1097/00000542-200001000-00043. PMID 10638928.  edit
  48. ^ a b Cánovas, L; Barros, C; Gómez, A; Castro, M; Castro, A (2002). "Use of intravenous tetracosactin in the treatment of postdural puncture headache: our experience in forty cases". Anesthesia and analgesia 94 (5): 1369. doi:10.1097/00000539-200205000-00069. PMID 11973227.  edit
  49. ^ Rouaud, T.; Lallement, F.; Choui, R.; Madigand, M. (2009). "Traitement de l’hypotension spontanée du liquide cérébrospinal par perfusion épidurale de sérum salé isotonique". Revue Neurologique 165 (2): 201. doi:10.1016/j.neurol.2008.05.006. PMID 19010507.  edit

Intracranial hypotension
Classification and external resources
ICD-10 G97.2
MeSH D019585

Intracranial hypotension refers to a decreased pressure (hypotension) of the intracranial pressure.

It may be generated during the treatment of hydrocephalus.[1]

"Spontaneous intracranial hypotension" (SIH), also known as a spontaneous low CSF (Cerebrospinal fluid) pressure headache, usually presents without any preexisting trauma or known violation of the epidural or thecal space.

Contents

Symptoms

The headache is usually orthostatic and related to traction on pain-sensitive intracranial and meningeal structures. The condition is benign and self limited. It may be associated with nausea, vomiting, horizontal diplopia, unsteadiness, vertigo, altered hearing, neck pain/stiffness, interscapular pain, and occasionally visual field cuts.

Diagnosis

The diagnosis is made based on history, exclusion of competing differential diagnoses, and the following studies: MRIs with gadolinium may display diffuse patchy meningeal enhancement, "sagging" of the brain, tonsilar descent, and posterior fossa crowding. This condition is associated with low CSF opening pressure on lumbar puncture (normal CSF pressure is at least 60 mmH2O or 590 Pa).[2]

Treatment

Although conservative management should by attempted, an epidural blood patch should be attempted, as it is the treatment of choice.

References

  1. Bromby A, Czosnyka Z, Allin D, Richards HK, Pickard JD, Czosnyka M (2007). "Laboratory study on "intracranial hypotension" created by pumping the chamber of a hydrocephalus shunt". Cerebrospinal Fluid Res 4: 2. doi:10.1186/1743-8454-4-2. PMID 17386089. PMC: 1851975. http://www.cerebrospinalfluidresearch.com/content/4//2. 
  2. Lay CM. Low Cerebrospinal Fluid Pressure Headache.Curr Treat Options Neurol. 2002 Sep;4(5):357-363

See also


Advertisements






Got something to say? Make a comment.
Your name
Your email address
Message