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Continuum (Minneapolis, Minn.) Jun 2021Spontaneous intracranial hypotension is a disorder caused by spinal CSF leakage. This article reviews the clinical presentation, diagnosis, and treatment of spontaneous... (Review)
Review
PURPOSE OF REVIEW
Spontaneous intracranial hypotension is a disorder caused by spinal CSF leakage. This article reviews the clinical presentation, diagnosis, and treatment of spontaneous intracranial hypotension.
RECENT FINDINGS
The hallmark symptom of spontaneous intracranial hypotension is acute orthostatic headache; however, clinical presentations can be heterogeneous. New evidence shows that lumbar puncture is not always necessary or sufficient to establish the diagnosis. Some patients may have normal opening pressure, which suggests that insufficiency of CSF volume (hypovolemia) rather than CSF pressure might be the underlying mechanism. Several neuroimaging modalities can aid in diagnosis and localization of the CSF leakage, including brain MRI, spinal MRI, CT myelography, digital subtraction myelography, and radionuclide cisternography. Complications, such as subdural hematoma, can lead to a change in the headache pattern and potentially life-threatening consequences. Conservative treatments, such as fluid supplementation, can provide temporary relief; however, epidural blood patches, especially targeted ones, are more effective and definitive. For patients with refractory spontaneous intracranial hypotension, surgical repair of spinal CSF leakages should be considered.
SUMMARY
Brain and spinal MRIs are important for the diagnosis and treatment of patients with spontaneous intracranial hypotension. Early treatment with epidural blood patches may be considered to shorten the disease duration and minimize the potential risk of complications.
Topics: Cerebrospinal Fluid Leak; Headache; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography
PubMed: 34048402
DOI: 10.1212/CON.0000000000000979 -
Current Pain and Headache Reports Jan 2021To provide an update on recent developments in the understanding, diagnosis, and treatment of CSF-venous fistula (CVF). (Review)
Review
PURPOSE OF REVIEW
To provide an update on recent developments in the understanding, diagnosis, and treatment of CSF-venous fistula (CVF).
RECENT FINDING
CVF is a recently recognized cause of spontaneous intracranial hypotension (SIH), an important secondary headache, in which an aberrant connection is formed between the spinal subarachnoid space and an adjacent spinal epidural vein permitting unregulated loss of CSF into the circulatory system. CVFs often occur without a concurrent epidural fluid collection; therefore, CVF should be considered as a potential etiology for patients with SIH symptomatology but without an identifiable CSF leak. Imaging plays a critical role in the detection and localization of CVFs, with a number of imaging techniques and provocative maneuvers described in the literature to facilitate their localization for targeted and definitive treatment. Increasing awareness and improving the localization of CVFs can allow for improved outcomes in the SIH patient population. Future prospective studies are needed to determine the diagnostic performance of currently available imaging techniques as well as their ability to inform workup and guide treatment decisions.
Topics: Cerebrospinal Fluid Leak; Fistula; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography; Subarachnoid Space; Veins
PubMed: 33475890
DOI: 10.1007/s11916-020-00921-4 -
Neurosurgery Clinics of North America Jul 2024Cerebrospinal fluid-venous fistulas (CSFVFs) were first described in 2014 and have since become an increasingly diagnosed cause of spontaneous intracranial hypotension... (Review)
Review
Cerebrospinal fluid-venous fistulas (CSFVFs) were first described in 2014 and have since become an increasingly diagnosed cause of spontaneous intracranial hypotension due to increased clinical recognition and advancements in diagnostic modalities. In this review, the authors discuss CSFVF epidemiology, the variety of clinical presentations, the authors' preferred diagnostic approach, recent advancements in diagnostic methods, treatment options, current challenges, and directions of future research.
Topics: Humans; Intracranial Hypotension; Cerebral Veins; Vascular Fistula; Cerebrospinal Fluid
PubMed: 38782524
DOI: 10.1016/j.nec.2024.02.003 -
PM & R : the Journal of Injury,... Jan 2016To determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain and function.
DESIGN
Prospective, double-blind, randomized controlled study.
SETTING
Outpatient physiatric spine practice.
PARTICIPANTS
Adults with chronic (≥6 months), moderate-to-severe lumbar diskogenic pain that was unresponsive to conservative treatment.
METHODS
Participants were randomized to receive intradiskal PRP or contrast agent after provocative diskography. Data on pain, physical function, and participant satisfaction were collected at 1 week, 4 weeks, 8 weeks, 6 months, and 1 year. Participants in the control group who did not improve at 8 weeks were offered the option to receive PRP and subsequently followed.
MAIN OUTCOME MEASURES
Functional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, the pain and physical function domains of the 36-item Short Form Health Survey, and the modified North American Spine Society (NASS) Outcome Questionnaire were used.
RESULTS
Forty-seven participants (29 in the treatment group, 18 in the control group) were analyzed by an independent observer with a 92% follow-up rate. Over 8 weeks of follow-up, there were statistically significant improvements in participants who received intradiskal PRP with regards to pain (NRS Best Pain) (P = .02), function (FRI) (P = .03), and patient satisfaction (NASS Outcome Questionnaire) (P = .01) compared with controls. No adverse events of disk space infection, neurologic injury, or progressive herniation were reported following the injection of PRP.
CONCLUSION
Participants who received intradiskal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over 8 weeks compared with controls. Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up. Although these results are promising, further studies are needed to define the subset of participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP injectate.
Topics: Adult; Double-Blind Method; Female; Follow-Up Studies; Humans; Injections, Spinal; Intervertebral Disc; Low Back Pain; Lumbar Vertebrae; Male; Myelography; Pain Measurement; Platelet-Rich Plasma; Prospective Studies; Treatment Outcome
PubMed: 26314234
DOI: 10.1016/j.pmrj.2015.08.010 -
Lakartidningen Oct 2023Spontaneous intracranial hypotension (SIH) is a disease presenting mostly with orthostatic head and neck pain due to a spontaneous cerebrospinal fluid (CSF) leak or a...
Spontaneous intracranial hypotension (SIH) is a disease presenting mostly with orthostatic head and neck pain due to a spontaneous cerebrospinal fluid (CSF) leak or a CSF-venous fistula in the spinal region. It demonstrates typical MRI findings with sagging of the brain causing tension of the meninges and sometimes the cranial nerves. It shares some clinical similarities with post puncture headache but differs in its pathophysiological cause, diagnosis, and treatment. Many patients remain misdiagnosed or wait too long for the correct diagnosis. The diagnostic work-up includes an MRI of the head and spine in search of typical SIH signs. Myelography and CT scans are performed to identify the location of the CSF leak or CSF-venous fistula. Treatment options may involve (1) initial conservative treatment with bed rest, caffein and fluids, (2) interventions such as epidural blood patch, fibrin patch, and embolization, or (3) surgical closure of the leak.
Topics: Humans; Intracranial Hypotension; Blood Patch, Epidural; Brain; Headache; Fistula
PubMed: 37782313
DOI: No ID Found -
AJR. American Journal of Roentgenology Dec 2021CSF-venous fistulas (CVFs), first described in 2014, are an important cause of spontaneous intracranial hypotension. CVFs can be challenging to detect on conventional... (Review)
Review
CSF-venous fistulas (CVFs), first described in 2014, are an important cause of spontaneous intracranial hypotension. CVFs can be challenging to detect on conventional anatomic imaging because, unlike other types of spinal CSF leak, they do not typically result in pooling of fluid in the epidural space, and imaging signs of CVF may be subtle. Specialized myelographic techniques have been developed to help with CVF identification, but these techniques are not yet widely disseminated. This article reviews the current understanding of CVFs, emphasizing correlations between venous anatomy and imaging findings as well as potential mechanisms for pathogenesis, and describes current imaging techniques used for CVF diagnosis and localization. These techniques are broadly classified into fluoroscopy-based methods, including digital subtraction myelography and dynamic myelography, and cross-sectional methods, including decubitus CT myelography and MR myelography with intrathecal injection of gadolinium. Knowledge of these various options, including their relative advantages and disadvantages, is critical in the care of patients with spontaneous intracranial hypotension. Investigation is ongoing, and continued advances in knowledge about CVFs as well as in optimal imaging detection are anticipated.
Topics: Cerebrospinal Fluid Leak; Fluoroscopy; Humans; Magnetic Resonance Imaging; Myelography; Tomography, X-Ray Computed; Vascular Fistula
PubMed: 34191547
DOI: 10.2214/AJR.21.26182 -
Der Nervenarzt Aug 2014In this review article the clinical manifestations, imaging findings, diagnostic and therapeutic approaches for intracranial hypotension are described. The typical... (Review)
Review
In this review article the clinical manifestations, imaging findings, diagnostic and therapeutic approaches for intracranial hypotension are described. The typical manifestation, orthostatic headache, may sometimes be masked by atypical manifestations including coma, frontotemporal dementia and symptoms associated with leptomeningeal hemosiderosis. Spinal and cranial magnetic resonance imaging (MRI) findings are not always unequivocal and the diagnostic and therapeutic approaches are controversially discussed: Searching for the underlying spinal leak(s) of cerebral spinal fluid (CSF) is considered to be unnecessary or done with different modalities, such as computed tomography (CT) myelography, gadolinium-enhanced myelography and digital subtraction myelography. Various treatment approaches including conservative therapy, blind, fluoroscopy-guided and CT-guided epidural blood patches, CT-guided fibrin injection and surgery exist.
Topics: Blood Patch, Epidural; Diagnostic Imaging; Fibrin Tissue Adhesive; Humans; Intracranial Hypotension; Neurosurgical Procedures; Vascular Surgical Procedures
PubMed: 25069435
DOI: 10.1007/s00115-013-3849-x -
Neuroimaging Clinics of North America Nov 2019Spinal MR imaging is excellent for identifying details of spinal anatomy, including intraspinal contents, neural foramina, joints, ligaments, intervertebral discs, and... (Review)
Review
Spinal MR imaging is excellent for identifying details of spinal anatomy, including intraspinal contents, neural foramina, joints, ligaments, intervertebral discs, and bone marrow. Cortical bony structures of the spine are better imaged using CT. Conventional and CT myelography is an alternative to MR imaging in those with contraindications to MR imaging or in evaluation of spinal cerebrospinal fluid leaks. Motion- and flow-related artifacts may occur during imaging and should not be mistaken for lesions. With advancements in MR imaging hardware and software, spinal MR imaging can expand its role in the delineation of normal and abnormal spinal anatomy.
Topics: Humans; Magnetic Resonance Imaging; Myelography; Spine; Tomography, X-Ray Computed
PubMed: 31677724
DOI: 10.1016/j.nic.2019.08.001 -
Radiographics : a Review Publication of... 2020CT myelography is an important imaging modality that combines the advantages of myelography and the high resolution of CT. It provides a detailed delineation of... (Review)
Review
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.
Topics: Humans; Myelography; Spinal Diseases; Tomography, X-Ray Computed
PubMed: 32058837
DOI: 10.1148/rg.2020190135 -
Handbook of Clinical Neurology 2016Myelography describes the instillation of intrathecal contrast media for the imaging evaluation of spinal canal pathology. The technique has evolved with the use of... (Review)
Review
Myelography describes the instillation of intrathecal contrast media for the imaging evaluation of spinal canal pathology. The technique has evolved with the use of progressively less toxic contrast agents over its 90-year history and the inclusion of advanced image acquisition technology, including both computed tomography (CT) and magnetic resonance imaging (MRI), in addition to plain radiographic projections. The use of myelography for routine evaluation of spinal disease has diminished greatly due to the advent of MRI which has superior soft-tissue contrast and is relatively non-invasive. However, it is still a critical technique for conventional indications, such as spinal stenosis, when MRI is contraindicated or nondiagnostic. It is also recognized as the study of choice for brachial plexus injury, radiation therapy treatment planning, and cerebrospinal fluid (CSF) leak. Modern myelographic procedural technique and a discussion of how it contributes to these current indications will be reviewed in this chapter.
Topics: Humans; Image Processing, Computer-Assisted; Myelography; Spinal Cord; Spinal Diseases
PubMed: 27432666
DOI: 10.1016/B978-0-444-53485-9.00010-6