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Clinical Neuroradiology Sep 2023The diagnostic work-up in patients with spontaneous intracranial hypotension (SIH) and spinal longitudinal extradural CSF collection (SLEC) on magnetic resonance imaging...
BACKGROUND AND PURPOSE
The diagnostic work-up in patients with spontaneous intracranial hypotension (SIH) and spinal longitudinal extradural CSF collection (SLEC) on magnetic resonance imaging (MRI) comprises dynamic digital subtraction myelography (dDSM) in prone position for leak detection. Dynamic computed tomography (CT) myelography (dCT-M) in prone position follows if the leak is not unequivocally located. A drawback of dCT‑M is a high radiation dose. This study evaluates the diagnostic needs of dCT-M examinations and measures to reduce radiation doses.
METHODS
Frequency, leak sites, length and number of spiral acquisitions, DLP and effective doses of dCT‑M were retrospectively recorded in patients with ventral dural tears.
RESULTS
Of 42 patients with ventral dural tears, 8 underwent 11 dCT‑M when the leak was not unequivocally shown on digital subtraction myelography. The median number of spiral acquisitions was 4 (range 3-7) and the mean effective radiation dose 30.6 mSv (range 13.1-62.16 mSv) mSv. Five of eight leaks were located in the upper thoracic spine (range C7/Th1-Th2/3). Bolus tracking of intrathecal contrast agent in dCT‑M was used to limit the number and length of spiral acquisitions.
DISCUSSION
A dCT‑M in prone position to localize a ventral dural tear is needed in every fifth patient with a SLEC on MRI. It is typically needed when the leak is located in the upper thoracic spine and when patients have broad shoulders. Measures to reduce the radiation dose include bolus tracking or to repeat the DSM with adjusted positioning of patient.
Topics: Humans; Intracranial Hypotension; Myelography; Cerebrospinal Fluid Leak; Retrospective Studies; Tomography, X-Ray Computed; Magnetic Resonance Imaging; Radiation Dosage
PubMed: 36867243
DOI: 10.1007/s00062-023-01269-z -
BMJ Case Reports May 2022A woman in her 40s presented with a 3-month history of intermittent bilateral daily headache of moderate intensity. She had severe headaches for almost 1 month prior...
A woman in her 40s presented with a 3-month history of intermittent bilateral daily headache of moderate intensity. She had severe headaches for almost 1 month prior to the presentation, which was aggravated by standing and relieved by lying down. She underwent a non-contrast CT of the head followed by MRI of the brain and spine. Neuroimaging of the brain showed features of intracranial hypotension and spine MRI myelography fast imaging employing steady state acquisition sequences confirmed the site of cerebrospinal fluid (CSF) leak. An epidural blood patch (EBP) was placed to close the CSF leakage site. She had significant improvement in her symptoms and repeat MRI at 4 weeks of follow-up showed resolution of imaging abnormalities. She became symptom-free without the requirement of additional EBP. Our report highlights the importance of suspecting and evaluating spontaneous intracranial hypotension in a patient presented with a typical orthostatic headache. Early intervention and keeping a low threshold for evaluation based on a few early clinical and imaging clues can lead to successful management of such cases.
Topics: Blood Patch, Epidural; Cerebrospinal Fluid Leak; Female; Headache; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography; Neuroimaging
PubMed: 35537766
DOI: 10.1136/bcr-2021-245222 -
Schweizer Archiv Fur Tierheilkunde Jun 2021A mixed breed dog was anesthetized for diagnostic myelography to investigate acute onset neck pain. Instead of contrast medium, 444 μg/kg medetomidine were...
A mixed breed dog was anesthetized for diagnostic myelography to investigate acute onset neck pain. Instead of contrast medium, 444 μg/kg medetomidine were inadvertently injected into the cerebromedullaris cisterna owing to a human error. Severe bradycardia, undetectable peripheral pulse, respiratory arrest and loss of pupillary, palpebral and corneal reflexes were observed immediately after injection. Profound hypothermia developed and esophageal temperature, measured 20 minutes after medetomidine injection, was 33 °C. Atipamezole at 1 mg/kg im was administered, followed by a second dose of 0,5 mg/kg iv 20 minutes thereafter. In the meantime, cardiorespiratory parameters and body temperature were monitored, and supportive care that included manually assisted pulmonary ventilation, active warming, and administration of 5 μg/kg/min dopamine was initiated. The dog's clinical condition improved within one hour from the beginning of supportive care, at which time ocular reflexes and swallowing returned, spontaneous ventilation was deemed as adequate and the trachea could be extubated. The dog was discharged in good clinical conditions five days later. Human error and distraction led to a potentially life-threatening complication in the dog of this report and could have possibly been prevented with the use of checklists and with a clearer definition of roles and responsibilities of the personnel involved prior to commencing the clinical procedure. Profound cardiovascular, respiratory, and thermoregulatory depression caused by intracisternal injection of medetomidine responded to parenteral administration of its antagonist and supportive care.
Topics: Adrenergic alpha-2 Receptor Antagonists; Animals; Dogs; Hypnotics and Sedatives; Imidazoles; Medetomidine; Medical Errors; Myelography; Treatment Outcome
PubMed: 34097637
DOI: 10.17236/sat00307 -
The Journal of Spinal Cord Medicine Mar 2020A Kirschner wire (K-wire) is a stainless steel pin with at least one sharpened tip that is mainly used for the internal fixation of bone fractures. While some cases of... (Review)
Review
CONTEXT
A Kirschner wire (K-wire) is a stainless steel pin with at least one sharpened tip that is mainly used for the internal fixation of bone fractures. While some cases of K-wire dislocation and migration have been reported as complications after fracture surgery, the intraspinal migration of a K-wire is rare. Herein, we report a case in which a K-wire used for sternal fixation 7 years earlier migrated into the spinal canal.
FINDINGS
A 68-year-old male suddenly sustained severe radiating pain and numbness in his left upper extremity, and walked to our hospital. He had mild weakness in the left wrist extensor muscles and the left extensor digitorum. CT-myelography revealed a K-wire penetrating into the spinal cord at C5-6. There was no injury of the trachea, esophagus, or blood vessels. The patient had a history of surgical infection after cardiovascular surgery seven years before, and had undergone surgical debridement and sternum fixation with two K-wires. One K-wire had broken, and part of it migrated upward. Using an anterior approach, we detected the tip of K-wire below the left sternocleidomastoid muscle. We cut the K-wire into 1 to 2-cm pieces and removed it piece by piece. His postoperative course was uneventful and the symptoms improved markedly after the surgery.
CONCLUSION
This is the first report of a K-wire that had been used for sternal fixation migrating into the spinal cord. This case illustrates that although rare, it is possible for a K-wire to migrate upward after sternal fixation.
Topics: Aged; Bone Wires; Cervical Vertebrae; Fracture Fixation, Internal; Humans; Male; Spinal Cord Injuries; Sternum; Tomography, X-Ray Computed
PubMed: 29334327
DOI: 10.1080/10790268.2017.1419915 -
Surgical Neurology International 2022We describe a case of long-standing intracranial hypotension caused by an iatrogenic arachnoid diverticulum. This case illustrates two learning points. First, excessive...
BACKGROUND
We describe a case of long-standing intracranial hypotension caused by an iatrogenic arachnoid diverticulum. This case illustrates two learning points. First, excessive CSF absorption may occur through an acquired arachnoid-epidural venous plexus at a dural defect. Second, a long-standing CSF leak may benefit from definitive surgical repair in the first instance.
CASE DESCRIPTION
A 55-year-old female, with known idiopathic intracranial hypertension, presented with disabling chronic low-pressure symptoms after having a lumboperitoneal shunt removed 5 years previously. MRI scan revealed a Chiari I malformation (CMI) and a small dural interruption at the L3/4 space. CT myelography confirmed the abnormality. Intraoperatively, a dural defect and arachnoid bleb with an overlying attachment of adipose tissue and a vessel were found. Postoperatively, the patient has marked resolution of her headaches and dizziness and is mobilizing independently.
CONCLUSION
Excessive CSF absorption appears to have occurred through an acquired arachnoid-epidural venous plexus. A high index of suspicion for intracranial hypotension is required in patients with low pressure symptoms and a CMI.
PubMed: 35673636
DOI: 10.25259/SNI_1084_2021 -
Case Reports in Neurological Medicine 2022Spontaneous intracranial hypotension (SIH) is a rare condition caused by a fluid (CSF) leak. It is diagnosed by clinical features that include an orthostatic headache...
Spontaneous intracranial hypotension (SIH) is a rare condition caused by a fluid (CSF) leak. It is diagnosed by clinical features that include an orthostatic headache combined with imaging findings demonstrating intracranial hypotension and a CSF leak. We present the case of a 45-year-old woman with an orthostatic headache who was found to have a sagging brain with a downward-displaced cerebellum and pachymeningeal enhancement with gadolinium contrast. This was initially misidentified as a Chiari I malformation, but the constellation of symptoms and MRI findings were later recognized as characteristic of SIH. Diagnosis of SIH and a CSF leak was confirmed with CT myelography. She was treated with a nontarget epidural blood patch, and her symptoms resolved. An orthostatic headache, a sagging brain, and pachymeningeal enhancement on MRI are highly specific for SIH, raising suspicion for this uncommon and often missed diagnosis.
PubMed: 35237456
DOI: 10.1155/2022/4438923 -
The Journal of Veterinary Medical... Sep 2022Cervical vertebral stenotic myelopathy (CVSM), a common cause of cervical spinal cord compression, is a neurological disease characterized by general proprioceptive...
Cervical vertebral stenotic myelopathy (CVSM), a common cause of cervical spinal cord compression, is a neurological disease characterized by general proprioceptive ataxia and weakness of hindlimbs that tends to develop in young adult Thoroughbred horses. Although male horses seem to be at increased risk for CVSM, the mechanism for the occurrence of sex differences in the prevalence of CVSM is still poorly understood. Hence, we hypothesized that sex differences in the development of cervical spinal cord and spinal canal would affect the development of CVSM. This study aimed to evaluate sex differences in the development of cervical spinal cord and spinal canal in Thoroughbred horses. A total of 29 Thoroughbred horses underwent computed tomographic myelography. Thereafter, the volumes of cervical spinal cord and spinal canal were calculated. Accordingly, male horses had significantly lager cervical spinal cord volume and cervical spinal cord-to-spinal canal volume ratio than those of female horses (P<0.05). Sex differences in the cervical spinal cord-to-spinal canal volume ratio gradually decreased until around 1,400 days of age. Younger male horses have narrower interspace between the cervical spinal cord and spinal canal than younger female horses, suggesting that an imbalanced cervical spinal cord and spinal canal growth is one of the causes of CVSM.
Topics: Animals; Cervical Cord; Female; Horse Diseases; Horses; Male; Sex Characteristics; Spinal Canal; Spinal Cord Compression; Spinal Cord Diseases; Spinal Stenosis
PubMed: 35944983
DOI: 10.1292/jvms.22-0234 -
Journal of Neurosurgery. Case Lessons Dec 2021Spinal subdural hygroma (SSH) is a rare pathological entity occurring as a complication of spinal surgery. It is different from spinal subdural hematoma due to blunt...
BACKGROUND
Spinal subdural hygroma (SSH) is a rare pathological entity occurring as a complication of spinal surgery. It is different from spinal subdural hematoma due to blunt trauma, anticoagulation therapy, spinal puncture, and rupture of vascular malformations.
OBSERVATIONS
The authors presented five patients with SSH who received decompression for lumbar stenosis. None had incidental durotomy. All presented postoperatively with unexpectedly severe symptoms, including back and leg pain and weakness. Postoperative magnetic resonance imaging (MRI) revealed SSH with a characteristic imaging finding termed the "flying bat" sign. Four patients underwent evacuation of SSH, with immediate and complete resolution of symptoms in three patients and improvement in one patient. One patient improved without additional surgery. At surgery, subdural collections were found to be xanthochromic fluid in three patients and plain cerebrospinal fluid (CSF) in one patient.
LESSONS
Unexpectedly severe back and leg pain and weakness after lumbar or thoracic spine surgery should raise suspicion of SSH. MRI and/or computed tomography myelography shows the characteristic findings termed the flying bat sign. Surgical evacuation is successful although spontaneous resolution can also occur. The authors hypothesized that SSH is due to CSF entering the subdural space from the subarachnoid space via a one-way valve effect.
PubMed: 36061085
DOI: 10.3171/CASE21291 -
Radiology Case Reports Oct 2020Use of intrathecal gadolinium for contrast-enhanced myelography and cisternography remains off-label and is currently not FDA-approved. We report a 70-year-old male...
Use of intrathecal gadolinium for contrast-enhanced myelography and cisternography remains off-label and is currently not FDA-approved. We report a 70-year-old male who underwent CT myelogram utilizing off-label high-dose intrathecal gadolinium who developed altered mental status and bilateral hearing loss. Workup ruled out meningitis (infectious and aseptic), infectious encephalopathy, encephalitis, and hypothyroidism. MRI of the brain and lumbar spine without contrast displayed fluid collection in L4-5 interspace and diffuse cerebrospinal fluid (CSF) hyperdensity consistent with intrathecal gadolinium. The patient eventually improved with high-dose IV dexamethasone and supportive care and resolution of diffuse CSF hyperdensity was observed on repeat MRI. There are limited data demonstrating the safety of low-dose intrathecal gadolinium due to which usage remains off-label. Our case highlights the need for caution when using substances for off-label indications and reinforces the usage of less invasive and noninvasive diagnostic modalities when possible.
PubMed: 32874398
DOI: 10.1016/j.radcr.2020.07.084 -
Journal of Neurosurgery. Case Lessons Feb 2023Spontaneous intracranial hypotension (SIH) is a relatively rare and underdiagnosed disease. SIH can lead to subdural hematomas (SDHs) and other complications. SDHs...
BACKGROUND
Spontaneous intracranial hypotension (SIH) is a relatively rare and underdiagnosed disease. SIH can lead to subdural hematomas (SDHs) and other complications. SDHs secondary to SIH are difficult to manage, with no consensus in management, and SDHs commonly recur if underlying SIH is not treated.
OBSERVATIONS
A 46-year-old male with vague sensory and orientation symptoms presented with bilateral SDHs, which were treated with middle meningeal artery (MMA) embolization and burr hole evacuation. The patient improved initially but had recurrent encephalopathy and SDHs. The patient received 3 epidural blood patches (EBPs) over 8 days with continued improvement. A 78-year-old female presented with headaches, and imaging revealed a left chronic SDH. She underwent MMA embolization and mini-craniotomy for SDH evacuation. Her symptoms returned and imaging revealed a recurrent SDH. Pan spine computed tomography myelography showed a high thoracic cerebrospinal fluid (CSF) leak. She underwent 3 EBPs over 8 days with neurological improvement and stabilization of her SDH.
LESSONS
The authors show that, if SDH recurs after initial treatment with MMA embolization, then SIH should be strongly considered and treated with EBPs. Further investigation is required to determine the role of targeted or blind EBPs and the use of imaging to find the source of occult CSF leaks causing SIH.
PubMed: 36748753
DOI: 10.3171/CASE22445