SciCombinator

Discover the most talked about and latest scientific content & concepts.

Concept: Orthostatic headache

28

BackgroundDecreased level of consciousness is a rare neurological manifestation of spontaneous intracranial hypotension (SIH), which typically presents with orthostatic headache. The optimal management of this uncommon presentation remains uncertain.MethodsWe analyzed the presentation, management and outcome of two patients in our institution and reviewed 22 patients reported in the literature with SIH and decreased level of consciousness, defined as any decrease in the patient’s Glasgow Coma Scale score.ResultsThere were 20 male and four female patients (M:F ratio of 5:1) with an average age of 52 years (range 37 to 68 years). There was a variable time interval of up to many months between the initial presentation of SIH and changes in the level of consciousness. An epidural autologous blood patch was eventually successful in 79% of the patients, although up to three trials were necessary in seven of these patients. Intrathecal saline infusion used as a temporizing measure resulted in excellent response within hours in five out of six patients who received this treatment. Drainage of the subdural collection either did not result in any sustained improvement or resulted in clinical deterioration in 12 out of 12 patients who received this treatment.ConclusionsIn the absence of a clinical trial because of the rarity of this entity, the treatment of SIH complicated by decreased level of consciousness remained controversial in the past. However, current collective experience supports early treatment of patients with SIH and decreased level of consciousness with one or more epidural blood patches. Fibrin glue and surgical duroplasty are the next steps in the management of patients in whom epidural blood patches fail. Drainage of the subdural collections may be detrimental.

Concepts: Patient, Neurology, Orthostatic hypotension, Glasgow Coma Scale, Coma, Result, Spontaneous cerebrospinal fluid leak, Orthostatic headache

0

Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, low CSF pressure and diffuse pachymeningeal enhancement on brain MRI. SIH results from spontaneous CSF leakage leading to brain sag. Sometimes, tearing of bridging veins may produce subdural hematomas (SDHs). Patients with SDH were identified retrospectively from 212 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, treatment and outcome of SDH. Thirty-five patients (16%), (6 women, 29 men; aged 33-68; mean, 50 years) with SDH were recruited. They were divided into two groups: initially withSIH diagnosed (n = 29) and undiagnosed (n = 6). After conservative treatment, the first group underwent a lumbar epidural blood patch (EBP) (n = 27) and emergent evacuation of symptomatic SDH (n = 2). After EBP, ten patients had enlarged SDH. Nine of them underwent evacuation of symptomatic SDH with mass effect (ME). In the second group, three patients with clinical worsening from SIH underwent, erroneously, evacuation of mild SDH. They worsened after the evacuation; after SIH diagnosis was made, they underwent one EBP (n = 2) and three EBPs (the patient with coma). The other three cases with symptomatic SDH with ME underwent evacuation with recurrence of SDH (n = 2). All 35 patients enjoyed a good outcome. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation. When an emergent evacuation is necessary before EBP, it is preferable to perform, after surgery, one early EBP before the patient gets up to prevent frequent recurrences of SDH by underlying CSF leakage.

Concepts: Traumatic brain injury, Intracranial pressure, Subdural hematoma, Hematoma, Subdural space, Headache, Spontaneous cerebrospinal fluid leak, Orthostatic headache

0

CSF hypovolemia is a core feature of spontaneous intracranial hypotension. Spontaneous intracranial hypotension is characterized by orthostatic headache and radiologic manifestations, including CSF along the neural sleeves, diffuse pachymeningeal enhancement, and/or venous engorgement. However, these characteristics are only qualitative. Quantifying intraspinal CSF volumes could improve spontaneous intracranial hypotension diagnosis and evaluation of hypovolemic statuses in patients with spontaneous intracranial hypotension. The purpose of this study was to compare intraspinal CSF volumes across spontaneous intracranial hypotension stages and to test the clinical applicability of these measures.

Concepts: Psychology, Shock, Neurological disorders, Spontaneous cerebrospinal fluid leak, Orthostatic headache, Intracranial hypotension, Spontaneous Intracranial Hypotension, Cerebrospinal fluid leak

0

We report a case of refractory spontaneous intracranial hypotension (SIH) following epidural anesthesia. In this case, typical clinical symptoms and concomitant use of regional anesthesia led to the misdiagnosis of SIH as post-dural puncture headache (PDPH). A 56-year-old man received a successful appendectomy under epidural anesthesia performed at a T11-T12 intravertebral space. About 20 h later, the patient started complaining about orthostatic headache when getting up from his lying position, then a PDPH was diagnosed. However, the patient did not respond well to conservative treatment. Three months later, the first epidural blood patch was performed at the L3-L4 level, however, the patient still had an orthostatic headache. Five days later, spine magnetic resonance imaging showed multiple meningeal diverticulum in the cervicothoracic junction, and computerized tomography myelography demonstrated a C5-C6 spinal dural tear suggesting cerebrospinal fluid leaks. Finally, the patient was diagnosed as SIH and received a second epidural blood patch at the T2-T3 level and responded with improvements in symptomatology. The patient was then discharged, and at a 2-year follow-up, he had fully recovered except for some remaining neck stiffness. This case illustrates that SIH was misdiagnosed as PDPH because of the common clinical symptoms and potentially confounding events (epidural/spinal anesthesia and assumption that it was a case of PDPH). It is important to carefully observe patients in such conditions and promptly conduct suitable diagnostic tests. For a successful treatment of SIH, a timely epidural blood patch should be considered as soon as the diagnosis is established.

Concepts: Medical terms, Medical imaging, Intracranial pressure, Magnetic resonance imaging, Lumbar puncture, Spontaneous cerebrospinal fluid leak, Epidural blood patch, Orthostatic headache

0

Spontaneous intracranial hypotension (SIH) is a neurological condition characterized by orthostatic headache (OH), low cerebrospinal fluid (CSF) pressure and diffuse pachymeningeal enhancement on brain magnetic resonance imaging (MRI). Hearing changes (HC) are also a common clinical finding. At present, epidural blood patch (EBP) is the most recommended treatment. Our study aimed at describing clinical variability of SIH patients. We also aimed at measuring the EBP efficacy on OH and HC in patients affected by SIH, by asking them to rate their levels of discomfort on a VAS. 28 consecutive patients were recruited. All of them complained about OH, 16 of them also reported HC. They were all treated with EBP. Two clinical psychologists interviewed them before and after the procedure, asking to rate the intensity of their OH and HC on a VAS at different time points: the day before the procedure, between 24 and 48 h after it and 2 months after treatment. Before EBP, patients rated their OH as 5 (IQR 2-7) and their HC as 4 (IQR 2-5.75). 24/48 h after EBP, a significant improvement in OH (median 0, IQR 0-0; p < 0.001) and HC (median 1, IQR 0-2; p < 0.05) was found. At follow up assessments, all patients reported a complete relief from their OH and four out of 16 patients only still reported mild HC. Our data show for the first time the early and durable efficacy of EBP on OH and HC in patients affected by SIH.

Concepts: Brain, Intracranial pressure, Magnetic resonance imaging, Neurology, Cerebrospinal fluid, Lumbar puncture, Spontaneous cerebrospinal fluid leak, Orthostatic headache

0

Headache is one of the most common clinical entities, and has a long list of differential diagnoses; however, one of the more uncommon causes of postural headache is spontaneous intracranial hypotension. It is important that clinicians be aware of this condition, as it is often overlooked, leading to invasive and unnecessary diagnostic testing. A good history and physical exam, paired with an MRI of the brain is sufficient to make the diagnosis of SIH, relieve the symptomology of the patient in a quick and efficient manner, and avoid costly invasive procedures.

Concepts: Medical terms, Diagnosis, Medical diagnosis, Physical examination, Orthostatic hypotension, Differential diagnosis, Spontaneous cerebrospinal fluid leak, Orthostatic headache

0

Spontaneous intracranial hypotension (SIH) usually occurs in the setting of a spontaneous cerebral spinal fluid (CSF) leak. We report the first description of a case of SIH caused by a CSF leak which improved after a targeted epidural patch with n-butyl cyanoacrylate (n-BCA) at the right T1-T2 level. An 81-year-old woman presented with an orthostatic headache for 6 days. MRI of the brain with contrast demonstrated low lying cerebellar tonsils, an engorged transverse sinus flow void, bifrontal small subdural fluid collections, and diffuse dural enhancement. CT myelography showed extravasation of intrathecal contrast at the right T1-T2 level. A targeted epidural patch was performed by injection of n-BCA through a catheter at the right T1-T2 level. After treatment, the patient’s symptoms immediately improved and she was without a headache at 1-year follow-up.

Concepts: Spinal cord, Brain, Intracranial pressure, Neurology, Cerebrospinal fluid, Meningitis, Spontaneous cerebrospinal fluid leak, Orthostatic headache

0

Spontaneous intracranial hypotension (SIH) usually occurs in the setting of a spontaneous cerebral spinal fluid (CSF) leak. We report the first description of a case of SIH caused by a CSF leak which improved after a targeted epidural patch with n-butyl cyanoacrylate (n-BCA) at the right T1-T2 level. An 81-year-old woman presented with an orthostatic headache for 6 days. MRI of the brain with contrast demonstrated low lying cerebellar tonsils, an engorged transverse sinus flow void, bifrontal small subdural fluid collections, and diffuse dural enhancement. CT myelography showed extravasation of intrathecal contrast at the right T1-T2 level. A targeted epidural patch was performed by injection of n-BCA through a catheter at the right T1-T2 level. After treatment, the patient’s symptoms immediately improved and she was without a headache at 1-year follow-up.

Concepts: Spinal cord, Brain, Intracranial pressure, Neurology, Cerebrospinal fluid, Meningitis, Spontaneous cerebrospinal fluid leak, Orthostatic headache

0

Spontaneous intracranial hypotension (SIH) is most commonly caused by cerebrospinal fluid (CSF) leakage. Therefore, we hypothesised that patients with orthostatic headache (OH) would show decreased optic nerve sheath diameter (ONSD) during changes from supine to upright position.

Concepts: Spinal cord, Intracranial pressure, Multiple sclerosis, Neurology, Cerebrospinal fluid, Neurological disorders, Spontaneous cerebrospinal fluid leak, Orthostatic headache

0

Spontaneous intracranial hypotension (SIH) has increasingly been recognized, and it is well known that SIH is sometimes complicated by chronic subdural hematoma (SDH). In this study, 55 cases of SIH with SDH were retrospectively analyzed, focusing on therapeutic strategies and outcomes. Of 169 SIH cases (75 males, 84 females), 55 (36 males, 19 females) were complicated by SDH. SIH was diagnosed based on clinical symptoms, neuroimaging, and/or low cerebrospinal fluid pressure. Presence of orthostatic headache and diffuse meningeal enhancement on magnetic resonance imaging were regarded as the most important criteria. Among 55 SIH with SDH cases, 13 improved with conservative treatment, 25 initially received an epidural blood patch (EBP), and 17 initially underwent irrigation of the hematomas. Of the 25 initially treated with EBP, 7 (28.0%) needed SDH surgery and 18 (72.0%) recovered fully without surgery. Of 17 SDH cases initially treated with surgery, 6 (35.7%) required no EBP therapy and the other 11 (64.3%) needed EBP and/or additional SDH operations. In the latter group, 2 cases had transient severe complications during and after the procedures. One of these 2 cases developed a hoarse voice complication. Despite this single, non-severe complication, all enrolled in this study achieved good outcomes. The present study suggests that patients initially receiving SDH surgery may need additional treatments and may occasionally have complications. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation.

Concepts: Brain, Magnetic resonance imaging, Cerebrospinal fluid, Subdural hematoma, Hematoma, Meninges, Spontaneous cerebrospinal fluid leak, Orthostatic headache