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Curious Case of Altered CSF Dynamics
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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 epidural patch treatment characteristics. Materials and methods: We retrospectively reviewed the electronic medical records and radiographic findings of 30 patients clinically treated for SIH at a single university hospital between January 2015 and December 2016. Clinical symptoms, imaging findings and epidural patch details including dates, injection location, and amount of blood/fibrin injected were recorded. Results: Of 30 SIH patients identified, 11/30 (37%) had a localized leak and 14/30 (47%) had a non-localized leak. The first modality to identify the leak was most commonly CT myelogram (17/25, 68%), followed by MRI spine (6/25, 24%) and MRI myelogram (2/25, 8%). The most frequent leak sites were C7–T1, C5–C6, and T10–T11 in decreasing order. All patients underwent CT-guided epidural patch, averaging 2.3 procedure sessions, 3.4 injection sites, and 7.8 mL of injectate per site. Conclusion: Spinal CSF leak remains a challenging diagnosis, with CT myelography most frequently confirming the diagnosis, supplemented by spine MRI and MRI myelography. Patients frequently require multiple injections at multiple sites, and physicians and patients should be aware of the possible need for repeat treatments. Given the most common sites of leak, empiric blood patch at the cervicothoracic or thoracolumbar junction should be considered if no definitive leak is identified. Keywords: Headache, Cerebrospinal fluid leak, Blood patch
Methods:
Between September 2015 and October 2017, a specialist interest group including neurology, neurosurgery, neuroradiology, ophthalmology, nursing, primary care doctors and patient representatives met. An initial UK survey of attitudes and practice in IIH was sent to a wide group of physicians and surgeons who investigate and manage IIH regularly. A comprehensive systematic literature review was performed to assemble the foundations of the statements. An international panel along with four national professional bodies, namely the Association of British Neurologists, British Association for the Study of Headache, the Society of British Neurological Surgeons and the Royal College of Ophthalmologists critically reviewed the statements.
Results:
Over 20 questions were constructed: one based on the diagnostic principles for optimal investigation of papilloedema and 21 for the management of IIH. Three main principles were identified: (1) to treat the underlying disease; (2) to protect the vision; and (3) to minimise the headache morbidity. Statements presented provide insight to uncertainties in IIH where research opportunities exist.
Conclusions:
In collaboration with many different specialists, professions and patient representatives, we have developed guidance statements for the investigation and management of adult IIH.
Introduction:
For the past half century, the mainstay of cerebrospinal fluid (CSF) shunting for Idiopathic Intracranial Hypertension (IIH) has been lumboperitoneal (LP) shunt surgery. LP shunt has been associated with higher failure rates compared to ventriculoperitoneal shunts. However, there is no uniformity in the reporting of complication and surgical revision rates.
The goals of this study were to understand better the complications and surgical revisions rates associated with LP shunt insertion in IIH patients with the objective of providing better information about the different therapeutical option’s outcomes when counseling for a better informed consent.
Material & Methods:
Twenty-six patients with IHH undergoing lumboperitoneal shunt surgery for the first time by the senior author at an academy tertiary-care institution were retrospectively reviewed. Presence of complications and surgical revisions were the two main outcomes variables. Logistic regression analysis was used first to assess if there was a correlation between preoperative patient characteristics and complications and second to evaluate if there was any association between preoperative patient characteristics or postsurgical complications and surgical revision.
Results:
Primary shunts were, inserted into 26 patients and 58% required revision surgery. Median time to surgical revision was 4 (3-22) months. Multivariate logistic analysis showed no statistical significant association between preoperative patient characteristics and postoperative complications as well as no relationship between either preoperative characteristics or complications and surgical revisions.
Conclusion:
Our data suggests that our revisions were mostly performed to reduce the rate of post-LP shunt tonsilar herniation. The introduction of newer hardware is expected to positively impact the symptoms and signs of overdrainage post-LP shunt and the need of revision.
Objective:
MRI abnormalities have been described in patients with increased intracranial pressure (ICP), including in those with idiopathic intracranial hypertension (IIH). Spontaneous CSF-filled outpouchings of the dura (meningoceles) and secondary CSF leaks can occur from elevated ICP in patients with IIH; however, few studies have evaluated these findings. Our objective was to evaluate the frequency of spontaneous intracranial meningoceles among IIH patients and determine their association with visual outcome.
Materials and methods:
We performed a retrospective case-control study of consecutive IIH patients between 2000 and 2011 who underwent MRI that included T2-weighted imaging. Demographics, presenting symptoms, CSF opening pressure, and visual outcome were collected for the first and last evaluations. Control subjects included patients without headache or visual complaints who had normal brain MRI results. Stratified analysis was used to control for potential confounding by age, sex, race, and body mass index.
Results:
We included 79 IIH patients and 76 control subjects. Meningoceles were found in 11% of IIH patients versus 0% of control subjects (p<0.003). Prominent Meckel caves without frank meningoceles were found in 9% of IIH patients versus 0% of control subjects (p<0.003). Among IIH patients, the presence of meningocele or prominent Meckel caves was not associated with demographics, symptoms, degree of papilledema, CSF opening pressure, visual acuity, or visual field defect severity.
Conclusion:
Meningoceles are significantly more common in IIH patients than in control subjects and can be considered an additional imaging sign for IIH. Meningoceles are not, however, associated with decreased CSF opening pressure or better visual outcome in IIH.