Intracranial Hypotension

Ventricular tumors are excised using both microscope and endoscope as the viewing device. Excision of these tumors requires corticectomy. After these corticectomies, brain has tendency to fall because of CSF drainage. Currently available retractor systems are fixed and thus can be traumatic. On the other hand few systems that require small corticectomy need stereotactic or navigation system aid. These all methods and equipment are costly. Our simple method of using a cylindrical channel retractor custom made out of 20 cc plastic syringe in OT helps in making minimum possible corticectomy. It gives surgeon minimally traumatic, inexpensive, hands free retractor.

We report 2 very unusual cases of thunderclap headache complicating minimally invasive medical procedures. In the first case headache developed as the consequence of a pneumocephalus caused by an inadvertent intrathecal puncture during oxygen-ozone therapy for lumbar disk herniation. The second case involved intracranial hypotension, caused by the persistence of the needle, used for epidural anesthesia, and then penetrated in the subarachnoid space.

Introduction In patients with Intracranial Hypotension Syndrome (IHS), we observed reduction of the angle between vein of the Galen (VOG) and internal cerebral vein (ICV), which returns to the baseline after treatment. We coin the term “venous hinge” to describe this dynamic process and discuss its importance in IHS. Methods A midsagittal T1W image showing both VOG and ICV in the same plane was reterospectively analyzed by three different neuroradiologists in 17 patients with IHS. The angle between the lines drawn along the main axis of VOG and ICV (venous hinge angle (VHA)) was measured and documented. This angle measured from the magnetic resonance imaging (MRI) of the 50 normal controls was also recorded. Paired t tests were used to compare the VHA between male and female controls and between patients of IHS and normal controls. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated. The VHA was also calculated after treatment of these patients and paired t test was done to look for significant change in the VHA after treatment. Results The mean VHA formed by the veins in the IHS and control groups were 65° (35–98°) and 91° (76–124°) respectively (P < 0.0001). At a VHA of 79°, the sensitivity, specificity, PPV, and NPV for diagnosis of IHS were 88.24%, 92%, 78.95%, and 95.83% respectively. In ten patients, follow-up MRI demonstrated normalization of the collapsing angle following appropriate treatment (p = 0.003). Conclusion We report a previously undescribed imaging finding in patients with IHS. Recognition of this sign may aid in the diagnosis of IHS.

We report three patients with spontaneous intracranial hypotension in whom spinal MR imaging revealed ventral extradural fluid collections that were centered at the cervicothoracic junction in two patients and extended throughout the entire spine in the third patient. These spinal fluid collections most likely resulted from the accumulation of CSF at the site of dural leakage. Knowledge of this association can be helpful in the selection of imaging studies to facilitate diagnosis and treatment.

Spontaneous Intracranial Hypotension is a syndrome involving reduced intracranial pressure secondary to a dural tear which occurs mostly due to connective tissue disorders such as Marfans Syndrome, and Ehler Danlos Syndrome. Patients with dural ectasias leading to CSF leakage into the subdural or epidural space classically present with orthostatic headaches and cranial nerve deficits mostly seen in cranial nerves V-VIII. Diagnosis of SIH is confirmed with the aid of neuroimaging modalities of which Cranial MR imaging is most widely used. SIH can be treated conservatively or with epidural blood patches which are now widely being used to repair dural tears, and their effectiveness is being recognized. Recently epidural injection of fibrin glue has also been used which has been found to be effective in certain patients.

A recently identified and treatable cause of spontaneous intracranial hypotension (SIH) is cerebrospinal fluid (CSF)-venous fistula, and a recently described computed tomography myelogram (CTM) finding highly compatible with but not diagnostic of this entity is the hyperdense paraspinal vein sign. We aimed to retrospectively measure the prevalence of the hyperdense paraspinal vein sign on CTMs in SIH patients without dural CSF leak, in comparison with control groups. Three CTM groups were identified: 1) SIH study group, which included dural CSF leak-negative standard CTMs performed for SIH, with early and delayed imaging; 2) Early control CTMs, which were performed for indications other than SIH, with imaging shortly after intrathecal contrast administration; 3) Delayed control CTMs, which included delayed imaging. CTMs were retrospectively reviewed for the hyperdense paraspinal vein sign by experienced neuroradiologists, blinded to the group assignment. All CTMs deemed by a single ...

Spontaneous intracranial hypotension (SIH) is an increasingly described entity, with over 70 cases reported in the literature. The classic triad includes orthostatic headache, diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI) with gadolinium, and low cerebrospinal fluid pressure (CSF) in the lateral decubitus (&lt; 60 mm H₂O) and sitting positions. We present four rare clinical presentations of SIH, two of which have not been previously described in the literature, to the best of our knowledge. Patient 1 presented with dyspnea, dysphagia, bilateral ptosis, diplopia and seizures. Patient 2 presented with a paradoxical positional pattern of orthostatic hypotension. In Patient 3, bilateral subdural hematomas (SDH) were encountered; while in Patient 4, a recurrent unilateral SDH requiring multiple surgical interventions was demonstrated. Although uncommon clinical presentations, all four cases of intracranial hypotension were spontaneous, demonstrated diagnostic MRI...

A 15-year-old girl with the &quot;MASS&quot; phenotype (meeting several of the minor criteria for Marfan syndrome) presents with a new onset low-pressure postural headache. Clinical features and magnetic resonance imaging suggested intracranial hypotension, which was confirmed with lumbar puncture. The pathophysiology and treatment of spontaneous intracranial hypotension are discussed.

Spontaneous intracranial hypotension is an increasingly recognized cause of new-onset, daily, persistent headaches. Although these headaches are similar to post-lumbar puncture headaches, characteristic differences include intracranial pachymeningeal enhancement, subdural fluid collections, and downward displacement of the brain. The identification of upper cervical epidural fluid collections as a false localizing sign in patients with SIH has provided significant insight into the selection of management options. We review a case of a 57-year-old woman who presented to our institution with progressive orthostatic headaches relieved by recumbency. The patient had no recent history of lumbar puncture, spinal, or intracranial procedure. The patient isolated the onset of symptoms to 3 weeks prior, when she was lifting heavy items in her home, and was diagnosed with SIH. Subsequently, she was found to have a C1-C2 epidural fluid collection. After much diagnostic consideration and review ...

Aim: Intracranial hypotension and epidural blood patch treatment for cerebrospinal fluid leakage can cause a variety of neurological complications. Herein, we aimed to describe a case of cerebral venous thrombosis as a rare complication.
Case Report: Forty-six year old female underwent open laminectomy at L4 level for disc herniation. After surgery, local anesthetic and corticosteroid injection was done for persistent back and extremity pain. After the procedure, severe orthostatic
headache was developed. Despite brain magnetic resonance imaging (MRI) was found in normal limits, the diagnosis of intracranial hypotension was established with the clinical findings. Epidural blood patch application with 5cc venous blood was done for peristant headache which made her headache free. Two days after the procedure, she became unconcious and started having epileptic seizures. Brain
MRI showed ischemia in bilateral frontal regions. MR venography showed total occlusion at sagittal superior venous sinus. Coagulation tests were found
within normal limits. Anticoagulant and anti-oedematous medications was started. Her neurological findings were resolved at the end of first month.
Conclusion: We report here the first case of cerebral venous infarction caused by intracranial hypotension and epidural blood patch treatment after lumbar disc surgery. This serious complication should be considered in patients with intracranial
hypotention who require epidural blood patch treatment

Spontaneous intracranial hypotension (SIH) is recognized with increasing frequency. A throbbing headache occurring or worsening in the upright position and improving after lying down, a so-called &#39;orthostatic headache&#39;, low cerebrospinal fluid (CSF) pressure, and diffuse pachymeningeal enhancement on brain magnetic resonance imaging (MRI) are the major features of the classic syndrome. These patients, who are admitted with fever, headache, and CSF findings revealing lymphocytic pleocytosis, elevated protein concentration, normal glucose levels, and negative culture results, are prone to be misdiagnosed with aseptic meningitis. The aims of this single-centre retrospective study were to determine the epidemiological, clinical, laboratory, and radiological features of patients initially evaluated as having aseptic meningitis but subsequently diagnosed with SIH, and to touch upon the key points of the differential diagnosis in daily infectious diseases practice. Patients referre...

Intracranial hypotension (IH) has been a known entity in neurocritical care since 1938. Even though many cases are spontaneous, the incidence of intracranial hypotension in the neurocritical care setting is increasing by virtue of the increased number of neurosurgical interventions. Whether spontaneous or secondary in etiology, diagnosis of IH usually requires the presence of orthostatic symptoms, including headaches and nausea with low opening CSF pressure. However, typical clinical features in the appropriate clinical context and imaging, even with normal CSF pressure, can indicate IH. In the neurocritical care setting, challenges for accurate semiology include altered sensorium and reduced levels of responsiveness for which many etiologies may exist, including metabolic dysfunction, traumatic brain injury, IH, or nonconvulsive status epilepticus (NCSE). The authors describe 3 patients whose clinical picture and electroencephalography (EEG) findings initially suggested NCSE but wh...

Introduction In patients with Intracranial Hypotension Syndrome (IHS), we observed reduction of the angle between vein of the Galen (VOG) and internal cerebral vein (ICV), which returns to the baseline after treatment. We coin the term “venous hinge” to describe this dynamic process and discuss its importance in IHS. Methods A midsagittal T1W image showing both VOG and ICV in the same plane was reterospectively analyzed by three different neuroradiologists in 17 patients with IHS. The angle between the lines drawn along the main axis of VOG and ICV (venous hinge angle (VHA)) was measured and documented. This angle measured from the magnetic resonance imaging (MRI) of the 50 normal controls was also recorded. Paired t tests were used to compare the VHA between male and female controls and between patients of IHS and normal controls. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated. The VHA was also calculated after treatment of these patie...

Spontaneous Intracranial Hypotension is a syndrome involving reduced intracranial pressure secondary to a dural tear which occurs mostly due to connective tissue disorders such as Marfans Syndrome, and Ehler Danlos Syndrome. Patients with dural ectasias leading to CSF leakage into the subdural or epidural space classically present with orthostatic headaches and cranial nerve deficits mostly seen in cranial nerves V-VIII. Diagnosis of SIH is confirmed with the aid of neuroimaging modalities of which Cranial MR imaging is most widely used. SIH can be treated conservatively or with epidural blood patches which are now widely being used to repair dural tears, and their effectiveness is being recognized. Recently epidural injection of fibrin glue has also been used which has been found to be effective in certain patients.

Spontaneous spinal CSF leakage with the development of intracranial hypotension is a well-described entity. Cerebrospinal fluid leaks, mostly from the thoracic spine, are the major cause of spontaneous intracranial hypotension (SIH). Conservative treatment options include hydration, oral caffeine, and epidural blood patching. Alternatively, open surgical correction of meningeal diverticula is a therapeutic option. The authors describe 4 cases of spontaneous spinal CSF leakage producing symptoms of intracranial hypotension. All patients had multiple spinal diverticula with an identified leaking level. The patients were treated using a minimally invasive approach via surgical correction of the meningeal diverticulum.

Spontaneous Intracranial Hypotension is a syndrome involving reduced intracranial pressure secondary to a dural tear which occurs mostly due to connective tissue disorders such as Marfans Syndrome, and Ehler Danlos Syndrome. Patients with dural ectasias leading to CSF leakage into the subdural or epidural space classically present with orthostatic headaches and cranial nerve deficits mostly seen in cranial nerves V-VIII. Diagnosis of SIH is confirmed with the aid of neuroimaging modalities of which Cranial MR imaging is most widely used. SIH can be treated conservatively or with epidural blood patches which are now widely being used to repair dural tears, and their effectiveness is being recognized. Recently epidural injection of fibrin glue has also been used which has been found to be effective in certain patients.