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Coronal images from a CT myelogram showing contrast extravasating along the course of the left L2 nerve root, called a localizing CSF leak. (B) T2-weighted images from a cervical spine MRI myelogram showing a fluid collection in the dorsal spinal canal extending over multiple segments, called a non-localizing CSF leak.
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Background and purpose: Spontaneous intracranial hypotension (SIH) is a significant, treatable cause of postural headache, although the best diagnostic approach to diagnosing cerebrospinal fluid (CSF) leaks remains uncertain. The aim of this study is to evaluate the most common techniques used to diagnose leaks, the most frequent leak sites, and ep...
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Context 1
... leak", or "no leak" according to the imaging characteristics. A study was classified as a localized leak when there were signs of CSF leak which could be attributed to a single focal anatomic site. For example, a leak was termed localized if contrast from a CT myelogram was visualized in the epidural space and extending along a nerve root sleeve (Fig. 1a). A study was classified as a non-localized leak when there were findings suggestive for CSF leak from visualization of contrast in the extrathecal compartment without identification of a definite single site. This included cases in which epidural extrathecal contrast was visualized over multiple vertebral segments or the entire spine ...
Context 2
... leak when there were findings suggestive for CSF leak from visualization of contrast in the extrathecal compartment without identification of a definite single site. This included cases in which epidural extrathecal contrast was visualized over multiple vertebral segments or the entire spine but a precise leak site could not be pinpointed (Fig. 1b). Cases with multiple Tarlov cysts were included in this category. A study was categorized as no leak when there was no imaging evidence of contrast leak. For each localized and non-localized leak study, the most likely spinal site of leak was recorded as follows. For non-localized abnormalities, the region of maximal extrathecal ...
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Spontaneous intracranial hypotension Systemic lupus erythematous CSF leak Pachymeningeal enhancement Venous engorgement CT myelography a b s t r a c t Spontaneous intracranial hypotension (SIH) associated with cerebrospinal fluid leak classically presents with postural headache. It is most commonly caused by the spontaneous dehiscence of a meningea...
Citations
... Russian Journal. 2022;10(4): [75][76][77][78][79][80][81][82] The authors are responsible for the originality of the data presented and the possibility of publishing illustrative material -tables, drawings, photographs of patients. ...
... В известной тактике лечения СВГ в начале обеспечивают: 1) постельный режим; 2) введение препаратов, содержащих кофеин, нейропротекторы, стероиды и ноотропы; 3) инфузионная и пероральная гидратация. При недостаточности этих мер на втором этапе оказания помощи применяют сложные инвазивные пособия от введения аутологичной крови или фибринового клея в эпидуральное пространство (процедура «epidural blood patch») LITERATURE REVIEWS до нейрохирургических операций для герметизации уточненного места утечки спинномозговой жидкости [70,[78][79][80][81]. ...
... Однако известные способы лечения СВГ при своем использовании, на наш взгляд, априори имеют некоторые недостатки: -консервативная помощь дает достаточное стойкое улучшение состояния пациентов от 25 до 75% случаев, при этом фактическая эффективность и оптимальная продолжительность постельного режима четко не определены и не доказаны до настоящего времени [66,78,79,82,83]; -практически отсутствуют стандартные фармакологические схемы лечения, специфично предназначенные для пациентов с СВГ [78,84,85]; -выполнение нейрохирургических операций нередко исключено в связи с отсутствием возможности идентифицировать место утечки спинномозговой жидкости [69]; -процедура «epidural blood patch» (EBP) не обеспечивает надежного отсутствия рецидива заболевания в 42% случаев и требует повторения в среднем трижды [71,80]; -не учитывается изначальное функциональное состояние ушного лабиринта. В доступной нам литературе как отечественной, так и иностранной, сообщений об применении «хирургического угнетения» лабиринта для уменьшения выраженности приступов головокружения при СВГ и с целью усиления и пролонгирования результата симптоматического лечения мы не встретили. ...
Vertigo and dizziness are often found among the complaints of patients when contacting doctors of various specialties. In this article we conducted a meta-analysis of 458 literature sources in the PubMed database, of which 87 publications received the most attention. Attention is paid to the late diagnosis of a number of symptomatically similar nosologies, the lack of specific research methods that could exclude or confirm with a high degree of confidence the presence of the patient intracranial hypotension syndrome (IHS), vestibular migraine (VM), Meniere's disease (BM), non-inflammatory perilymphatic fistulas of the labyrinth windows (NPFLW). Due to the complexity of the diagnosis of these pathologies, the possibility of inaccuracies in the statistical data is allowed. This may lead to an overestimation of the mentioned prevalence of the most well-known diseases with a similar symptom complex, and to insufficient or untimely identification of the true causes of suffering of the patient. The high frequency of occurrence of cochleovestibular complaints in IHS is emphasized, and often their incorrect interpretation, which leads to erroneous diagnoses. The purpose of research. The optimization of diagnostic search in cochleovestibular disorders with the determination of indications for a new type of surgical treatment of patients with IHS with the evaluation of the results of the treatment. Material and methods. Authors present their own experience in the diagnosis and treatment of 36 patients with IHS, including 27 women and 9 men, aged 26 to 72 years, with vestibulopathies of unknown origin, who, based on the analysis of the course of the disease, were diagnosed with IHS. To relieve or reduce the severity of vertigo attacks in IHS and to enhance and prolong the result of symptomatic treatment the use of selective laser destruction (KTP radiation with a wavelength of 0.53 microns) of the receptor apparatus of the horizontal semicircular labyrinth channel is proposed. Results. The information content of a number of audiometric and otoneurological tests is shown. Emphasis is placed on the validity of “impact” audiometric tests (with head tilt, hyperventilation, and caffeine administration), associated with changes in intracranial pressure. The authors present their own clinical observation of a 40-year- old patient with IHS, who received the author's surgical treatment. During the two-year catamnestic observation, no negative dynamics were observed. Conclusions. Not only a neurologist, but also an otorhinolaryngologist should take an active part in the recognition of IHS. In vestibulopathies, it is advisable to expand the indications for performing “impact” audiometric tests, which improves differential diagnosis with symptomatically similar diseases. Dynamic monitoring of patients with IHS who underwent combined treatment with the use of exposure a pulsed high-energy laser on the semicircular channel of the labyrinth, confirms its effectiveness. Identification of interest of the peripheral department the cochleovestibular analyzer, even with the leading central genesis of the underlying pathology, allows us to expand the reasonable selection of patients for high-tech otorhinolaryngological surgical interventions.
Головокружение – одна из частых жалоб пациентов при обращении к врачам различных специально- стей. В настоящей работе проведен мета-анализ 458 литературных источников базы PubMed, из кото- рых наибольшее внимание обращено на 87 публикаций. Уделено внимание поздней диагностике ряда симптоматически схожих нозологий, отсутствию специфических методов исследования, которые могли бы исключить или подтвердить с высокой степенью достоверности наличие у пациента синдрома вну- тричерепной гипотензии (СВГ), вестибулярной мигрени (ВМ), болезни Меньера (БМ), невоспалительных перилимфатических фистул окон лабиринта (НПФОЛ). Из-за сложности диагностики этих патологий до- пускается возможность неточностей в статистических данных. Это может вести как к завышению распро- страненности наиболее известных заболеваний со схожим симптомокомплексом, так и к недостаточному или несвоевременному выявлению истинных причин страданий заболевшего человека. Подчеркивается высокая частота встречаемости при СВГ кохлеовестибулярных жалоб и нередко их неверная трактовка, что ведет к ошибочным диагнозам. Цель исследования. Оптимизация диагностического поиска при кохлеовестибулярных нарушениях с определением показаний к новому виду оперативного лечения больных СВГ с оценкой результатов проведенного лечения. Материал и методы. Представлен собственный опыт диагностики и лечения 36 больных СВГ, из них 27 женщин и 9 мужчин в возрасте от 26 до 72 лет с вестибулопатиями неясного генеза, у которых на основа- ниианализатечениязаболеваниядиагностированСВГ.Длякупированияилиуменьшениявыраженности приступов головокружения при СВГ и с целью усиления и пролонгирования результата симптоматического лечения предложено применение селективной лазерной деструкции (КТР-излучение с длиной волны 0,53 мкм) рецепторного аппарата горизонтального полукружного канала лабиринта. Результаты. Показана информативность ряда аудиометрических и отоневрологических тестов. Сделан акцент на валидность «нагрузочных» аудиометрических проб (с наклоном головы, с гипервентиляцией и введением кофеина), связанных с изменением внутричерепного давления. Представленособственноеклиническоенаблюдениепациента40летсСВГ,которомуоказанаавторская оперативная помощь. За время двухлетнего катамнестического наблюдения отрицательной динамики не отмечено. Выводы. В распознавании СВГ надлежит принимать активное участие не только неврологу, но и отори- ноларингологу. При вестибулопатиях целесообразно расширить показания к выполнению «нагрузочных» аудиометрических тестов, что улучшает дифференциальную диагностику с симптоматически схожими заболеваниями. Динамическое наблюдение за больными СВГ, которым проведено комбинированное ле- чение с применением воздействия импульсного высокоэнергетического лазера на полукружный канал лабиринта, подтверждает его эффективность. Выявление заинтересованности периферического отдела кохлеовестибулярного анализатора, даже при ведущем центральном генезе основной патологии, позво- ляет расширить обоснованный отбор пациентов для высокотехнологичных оториноларингологических оперативных вмешательств.
... Spontaneous intracranial hypotension (SIH) is an increasingly recognized entity caused by idiopathic cerebrospinal fluid (CSF) leakage through the suspected tear in the dural sac of the spinal cord [1]. The CSF hypovolemia induces downward traction of the brain and pain-sensitive structures, leading to the manifestation of SIH-typical orthostatic headache [2]. ...
Objective
Spontaneous intracranial hypotension (SIH) can be effectively treated by epidural blood patch (EBP) following the primary unsuccessful conservative therapy. Nevertheless, multi-site cerebrospinal fluid (CSF) leaks or those originating at the cervical or thoracic spine remain therapeutically challenging. Therefore, this study aimed to present our experience in the treatment of thoracic CSF leaks using epidural catheters for the EBP infusion.
Methods
Three patients presenting with typical orthostatic headaches were qualified for an EBP procedure. Preoperative MRI scans, myelography, and CT myelography were performed. Additionally, delayed CT myelography was repeated after 3 h to identify the CSF leakage site. Patients were followed-up clinically and radiologically for three months.
Results
The CT myelography identified CSF leak at the T2–3 (case 1), T5–12 (case 2), and T3–7 level (Case 3). A 0.06" diameter lumbar drainage catheter (Case 1 and 2) or Abbot's spinal cord stimulation (SCS) catheter (Case 3) was inserted epidurally through the lower thoracic/lumbar single-entry point and advanced into the identified thoracic leak site. The average volume of injected blood was 15.7 ml. No procedure-related complications were observed, and all patients improved clinically.
Conclusions
Epidural catheters remain safe and effective in treating thoracic and multi-site CSF leaks. In addition, Abbot's SCS catheter was found superior to the lumbar drainage catheter due to higher rigidity and bigger diameter despite being shorter than the lumbar drainage catheter.
... Imaging findings such as pachymeningeal enhancement, subdural collections, intracranial venous engorgement, pituitary enlargement, and decreased optic nerve sheath diameter at CT or MRI are suggestive of SIH (31,32). The goal of spine imaging in SIH is to identify the location of the CSF leak (31,34). T2weighted "virtual myelography" of the spine can demonstrate an epidural fluid collection to help locate the site of CSF leak for a targeted epidural blood patch. ...
... In cases of CSF venous fistula, CT myelography may show a "hyperdense paraspinal vein" sign, presumably secondary to passage of myelographic contrast material through a CSF venous fistula into a paraspinal vein (35). Although not as sensitive as CT myelography, MR myelography with gadolinium-based contrast agent enhancement can be performed in a select group of patients who are able to undergo MRI and have a high pretest probability of CSF leak, but in whom CT myelography findings were negative for CSF leak (34,36). ...
CT myelography is an important imaging modality that combines the advantages of myelography and the high resolution of CT. It provides a detailed delineation of pathologic spine conditions, especially those involving the thecal sac and its contents. However, the role of CT myelography has dramatically and appropriately decreased with the advent of MRI, which provides a noninvasive method to demonstrate pathologic spine conditions with high signal intensity in soft tissues. At the present time, CT myelography is often performed in patients who require evaluation of the thecal sac but have a contraindication to undergoing MRI. However, there remain many situations in which CT myelography is indicated and plays a critical role in patient treatment. The authors review common and uncommon indications for CT myelography and demonstrate various pathologic conditions in which CT myelography plays a vital role in patient treatment in this modern era of MRI.©RSNA, 2020.
Background
Accidental dural puncture (ADP) is the most frequent major complication when performing an epidural procedure in obstetrics. Consequently, loss of pressure in the cerebrospinal fluid (CSF) leads to the development of post‐dural puncture headache (PDPH), which occurs in 16%–86% of cases. To date, the efficacy of epidural fibrin patches (EFP) has not been evaluated in a controlled clinical trial, nor in comparative studies with epidural blood patches (EBP).
Methods
The objective of the present study was to compare the efficacy of EFP with respect to EBP for the treatment of refractory accidental PDPH. This prospective, randomized, open‐label, parallel, comparative study included 70 puerperal women who received an EBP or EFP (35 in each group) after failure of the conventional analgesic treatment for accidental PDPH in a hospital.
Results
A higher percentage of women with EFP than EBP achieved complete PDPH relief after 2 (97.1% vs. 54.3%) and 12 h (100.0% vs. 65.7%) of the patch injection. The percentage of patients who needed rescue analgesia was significantly lower with EFP after 2 (2.9% vs. 48.6%) and 12 h (0.0% vs. 37.1%). After 24 h, PDPH was resolved in all women who received EFP. The recurrence of PDPH was reported in one woman from the EBP group (2.9%), who subsequently required a second patch. The mean length of hospital stay was significantly lower with EFP (3.9 days) than EBP (5.9 days). Regarding satisfaction, the mean value (Likert scale) was significantly higher with EFP (4.7 vs. 3.0).
Conclusions
EFP provided better outcomes than EBP for the treatment of obstetric PDPH in terms of efficacy, safety, and patient satisfaction.
CT myelography is an important imaging modality that combines the advantages of myelography and the high resolution of CT. It provides a detailed delineation of pathologic spine conditions, especially those involving the thecal sac and its contents. However, the role of CT myelography has dramatically and appropriately decreased with the advent of MRT, which provides a noninvasive method to demonstrate pathologic spine conditions with high signal intensity in soft tissues. At the present time, CT myelography is often performed in patients who require evaluation of the thecal sac but have a contraindication to undergoing MRI. However, there remain many situations in which CT myelography is indicated and plays a critical role in patient treatment. The authors review common and uncommon indications for CT myelography and demonstrate various pathologic conditions in which CT myelography plays a vital role in patient treatment in this modern era of MRI.
Objectives:
To investigate the pooled diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension (SIH).
Methods:
A literature search of the MEDLINE/PubMed and Embase databases was conducted until July 25, 2021, including studies with the following inclusion criteria: (a) population: patients with newly diagnosed SIH; (b) diagnostic modality: MR myelography or MR myelography with intrathecal gadolinium for evaluation of CSF leakage; (c) outcomes: diagnostic yield of MR myelography or MR myelography with intrathecal gadolinium. The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects modeling was used to calculate the pooled estimates. Subgroup analysis regarding epidural fluid collection and meta-regression were additionally performed.
Results:
Fifteen studies with 643 patients were included. Eight studies used MR myelography with intrathecal gadolinium, and 11 used MR myelography. The overall quality of the included studies was moderate. The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) and that of MR myelography with intrathecal gadolinium was 83% (95% CI, 51-96%). There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium (p = 0.512). In subgroup analysis, the pooled diagnostic yield of the epidural fluid collection was 91% (95% CI, 84-94%). In meta-regression, the diagnostic yield was unaffected regardless of consecutive enrollment, magnet strength, or 2D/3D.
Conclusions:
MR myelography had a high diagnostic yield in patients with SIH. MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.
Key points:
• The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) in patients with spontaneous intracranial hypotension. • There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium. • MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.
