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Wouter I Schievink - One of the best experts on this subject based on the ideXlab platform.
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Diagnostic criteria for Headache due to spontaneous intracranial hypotension: A perspective
Headache, 2011Co-Authors: Wouter I Schievink, Stephen Silberstein, Bahram Mokri, Marie-germaine Bousser, David William Dodick, Peter James GoadsbyAbstract:The clinical and radiographic manifestations of spontaneous intracranial hypotension are highly variable and many patients do not satisfy the 2004 International Classification of Headache Disorders criteria. We developed new diagnostic criteria for spontaneous intracranial hypotension based on cases we have seen reflecting the variable manifestations of the disorder. These criteria provide a basis for change when the classification criteria are next revised. The diagnostic criteria consist of A, Orthostatic Headache; B, the presence of at least one of the following: low opening pressure (≤ 60 mm H(2) O), sustained improvement of symptoms after epidural blood patching, demonstration of an active spinal cerebrospinal fluid leak, cranial magnetic resonance imaging changes of intracranial hypotension (eg, brain sagging or pachymeningeal enhancement); C, no recent history of dural puncture; and D, not attributable to another disorder.
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spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm
Journal of Neurosurgery, 2009Co-Authors: Wouter I Schievink, David Palestrant, Marcel M Maya, George RappardAbstract:Spontaneous spinal CSF leaks are best known as a cause of Orthostatic Headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray–white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvemen...
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Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm
Journal of Neurosurgery, 2008Co-Authors: Wouter I Schievink, David Palestrant, Marcel M Maya, George RappardAbstract:Spontaneous spinal CSF leaks are best known as a cause of Orthostatic Headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray–white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.
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recurrent spontaneous spinal cerebrospinal fluid leak associated with nude nerve root syndrome case report
Neurosurgery, 2003Co-Authors: Wouter I Schievink, Line Jacques, Volker K H Sonntag, Edward C BenzelAbstract:OBJECTIVE AND IMPORTANCE: Spontaneous spinal cerebrospinal fluid (CSF) leaks have been noted occasionally at multiple sites in the same patient, but recurrent spontaneous spinal CSF leaks have not been documented. We describe a patient with a recurrent CSF leak who was found at surgery to have an absence of the entire nerve root sleeve at multiple thoracic levels. CLINICAL PRESENTATION: A 29-year-old woman bodybuilder noted an excruciating Orthostatic Headache associated with nausea. The neurological examination was unremarkable, and a magnetic resonance imaging examination showed the typical changes of intracranial hypotension. Computed tomographic myelography showed an extensive bilateral lower cervical CSF leak. INTERVENTION: The patient underwent bilateral lower cervical nerve root explorations, and several small dural holes were found. The CSF leaks were repaired, but 3 months later, computed tomographic myelography showed a new CSF leak in the midthoracic area. A thoracic laminectomy was performed, and several nerve roots were found to be completely devoid of dura. After the CSF leaks were repaired, there was significant improvement in her Headaches. CONCLUSION: A recurrent spontaneous spinal CSF leak may occur in patients with intracranial hypotension at a site previously documented not to be associated with a CSF leak. Absent nerve root sleeves may be found in patients with spontaneous spinal CSF leaks ("nude nerve root" syndrome), and these patients may be at increased risk of developing a recurrent CSF leak.
George Rappard - One of the best experts on this subject based on the ideXlab platform.
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spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm
Journal of Neurosurgery, 2009Co-Authors: Wouter I Schievink, David Palestrant, Marcel M Maya, George RappardAbstract:Spontaneous spinal CSF leaks are best known as a cause of Orthostatic Headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray–white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvemen...
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Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm
Journal of Neurosurgery, 2008Co-Authors: Wouter I Schievink, David Palestrant, Marcel M Maya, George RappardAbstract:Spontaneous spinal CSF leaks are best known as a cause of Orthostatic Headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray–white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.
David William Dodick - One of the best experts on this subject based on the ideXlab platform.
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sensitivity of mri of the spine compared with ct myelography in Orthostatic Headache with csf leak
Neurology, 2013Co-Authors: Amaal J Starling, Fatima Hernandez, Joseph M Hoxworth, Terrence L Trentman, Rashmi B Halker, Bert B Vargas, Eric V Hastriter, David William DodickAbstract:Objective: To investigate the sensitivity of MRI of the spine compared with CT myelography (CTM) in detecting CSF leaks. Methods: Between July 1998 and October 2010, 12 patients with Orthostatic Headache and a CTM-confirmed spinal CSF leak underwent an MRI of the spine with and without contrast. Using CTM as the gold standard, we retrospectively investigated the sensitivity of spinal MRI in detecting a CSF leak. Results: Eleven of 12 patients with a CSF leak documented by CTM also had extradural fluid collections on spinal MRI (sensitivity 91.7%). Six patients with extradural fluid collections on spinal MRI also had spinal dural enhancement. Conclusion: When compared with the gold standard of CTM, MRI of the spine appears to be a sensitive and less invasive imaging modality for detecting a spinal CSF leak, suggesting that MRI of the spine should be the imaging modality of first choice for the detection of spinal CSF leaks.
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Diagnostic criteria for Headache due to spontaneous intracranial hypotension: A perspective
Headache, 2011Co-Authors: Wouter I Schievink, Stephen Silberstein, Bahram Mokri, Marie-germaine Bousser, David William Dodick, Peter James GoadsbyAbstract:The clinical and radiographic manifestations of spontaneous intracranial hypotension are highly variable and many patients do not satisfy the 2004 International Classification of Headache Disorders criteria. We developed new diagnostic criteria for spontaneous intracranial hypotension based on cases we have seen reflecting the variable manifestations of the disorder. These criteria provide a basis for change when the classification criteria are next revised. The diagnostic criteria consist of A, Orthostatic Headache; B, the presence of at least one of the following: low opening pressure (≤ 60 mm H(2) O), sustained improvement of symptoms after epidural blood patching, demonstration of an active spinal cerebrospinal fluid leak, cranial magnetic resonance imaging changes of intracranial hypotension (eg, brain sagging or pachymeningeal enhancement); C, no recent history of dural puncture; and D, not attributable to another disorder.
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Spontaneous intracranial hypotension
Current Pain and Headache Reports, 2007Co-Authors: Todd J. Schwedt, David William DodickAbstract:Spontaneous intracranial hypotension (SIH) is caused by leakage of cerebrospinal fluid (CSF), with resultant CSF hypovolemia and intracranial hypotension. Although in some patients SIH may be preceded by minor trauma, it often occurs in the absence of any identifiable initiating event. Orthostatic Headache is the primary clinical manifestation, usually accompanied by one or more other symptoms of SIH. Diagnosis can be reached by a combination of imaging studies, which may include MRI with gadolinium, nuclear cisternography, and myelography. Treatment ranges from conservative management, such as bed rest and hydration, to invasive procedures, such as lumbar puncture with autologous blood patch, CT-guided fibrin glue injection at the site of the leak, and open surgical intervention. Outcomes vary from complete resolution of CSF leak with alleviation of symptoms to continued and/or recurrent leaks with chronic unremitting symptomatology.
Anna Savino - One of the best experts on this subject based on the ideXlab platform.
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epidural blood patch in trendelenburg position pre medicated with acetazolamide to treat spontaneous intracranial hypotension
European Journal of Neurology, 2010Co-Authors: E Ferrante, Ines Arpino, R Wetzl, Alessandra Citterio, Anna SavinoAbstract:Background: Spontaneous intracranial hypotension (SIH) is characterized by Orthostatic Headache, diffuse pachymeningeal enhancement on brain magnetic resonance imaging (MRI) and low cerebrospinal fluid (CSF) pressure. Treatment ranges from conservative management, such as bed rest, overhydration and caffeine, to invasive procedures, such as the autologous epidural blood patch (EBP), computed tomography (CT)-guided fibrin glue injection at the site of the leak and open surgical intervention. EBP has emerged as the treatment of choice for SIH when initial conservative measures fail to bring relief. Methods: Forty-two patients with SIH were treated with lumbar autologous EBP in Trendelenburg position preceded by pre-medication with acetazolamide. Results: A complete recovery was obtained in all patients after one (90%), two (5%) or three (5%) EBPs. After EBP, two patients (5%) also performed evacuation of bilateral chronic subdural hematoma with mass effect. Conclusions: Spontaneous intracranial hypotension can be effectively cured by lumbar autologous EBP in Trendelenburg position pre-medicated with acetazolamide.
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coma resulting from spontaneous intracranial hypotension treated with the epidural blood patch in the trendelenburg position pre medicated with acetazolamide
Clinical Neurology and Neurosurgery, 2009Co-Authors: E Ferrante, Ines Arpino, Alessandra Citterio, Anna SavinoAbstract:A 62-year-old man had a new onset of severe, Orthostatic Headache which eventually progressed to a stupor and a coma 3 weeks later. A computed tomography (CT) scan showed bilateral chronic subdural haematoma and magnetic resonance imaging (MRI) of the brain showed the typical findings of spontaneous intracranial hypotension (SIH). After pre-medication with acetazolamide, he was treated with three lumbar autologous epidural blood patches (EBPs) and kept in the Trendelenburg position, with full recovery. The first lumbar autologous EBP was ineffective and the second was only partially effective because of incorrect execution of the procedure as shown by spinal neuroimaging examination post-EBP. A spinal neuroimaging examination post-EBP is therefore to be recommended in order to confirm the correct execution of procedure. Pre-medication with acetazolamide and keeping the patient in the Trendelenburg position could reduce the flow of spinal cerebrospinal (CSF) leak favouring sealing of the hole.
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spontaneous intracranial hypotension syndrome report of twelve cases
Headache, 2004Co-Authors: Enrico Ferrante, Anna Savino, Grazia Sances, Giuseppe NappiAbstract:Purpose.—To investigate clinical, MRI, and radioisotope findings and therapeutic outcome of the syndrome of spontaneous intracranial hypotension (SIH). Background.—Spontaneous intracranial hypotension is characterized by Orthostatic Headache, low CSF pressure, and MRI findings of diffuse pachymeningeal gadolinium enhancement without previous history of head trauma or lumbar puncture. Spontaneous CSF leakage from a spinal dural tear has been suggested as the underlying pathogenic mechanism of SIH. Most patients recover without sequelae, but subdural collections have been described in a few. Methods.—Twelve consecutive patients (10 females, 2 males, mean age 39 years) with Headache related to the syndrome of spontaneous intracranial hypotension were investigated. Results.—Eleven patients presented Orthostatic Headache, one patient had continuous nonpostural Headache. Additional clinical symptoms included nausea, vomiting, tinnitus, diplopia, and back pain. All the patients had low CSF opening pressure, seven had increased CSF albumin, and four had pleocytosis. Brain MRI showed diffuse pachymeningeal gadolinium enhancement. Other features included subdural fluid collections (hematoma/hygroma) in four patients, downward displacement of the brain in four patients, and enlargement of the pituitary gland in one patient. Radioisotope cisternography results indicated, in two patients, a CSF leakage site in the cervico-thoracic region, and in one patient showed limited ascent of the tracer to the cerebral convexity and early appearance of radioisotope in the bladder. All the patients had complete resolution of Headache with conservative treatment. Conclusions.—Patients with SIH have distinct MRI and sometimes radioisotope cisternographic abnormalities and generally respond favorably to conservative management.
Ji Hee Hong - One of the best experts on this subject based on the ideXlab platform.
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Epidural Blood Patches in a Patient With Multi-level Cerebrospinal Fluid Leakage That Was Induced by
2013Co-Authors: Spontaneous Intracranial Hypotension, Sae Young Kim, Ji Hee HongAbstract:Spontaneous intracranial hypotension (SIH) is considered to be a very rare disorder. It is characterized by an Orthostatic Headache that is aggravated with the patient in the upright position and it is relieved by the patient assuming the supine position. SIH is caused by a spontaneous spinal cerebrospinal fluid leakage without the patient having undergone trauma, surgery or dural puncture or having any other significant medical history. An autologous epidural blood patch (EBP) is effective in relieving SIH. We report here on a case of SIH with cerebrospinal fluid leakage at the upper cervical vertebral level and the middle thoracic vertebral level. The points of leakage were identified by radionuclide cisternography, and this patient was successfully managed by injecting an EBP at each level of leakage. (Korean J Pain 2010; 23: 46-50) Key Words: blood patch, epidural, Headache, intracranial hypotension, spontaneous. Spontaneous intracranial hypotension (SIH) is a rare disease that occurs in 5 out of every 100,000 people [1]. It is characterized by an Orthostatic Headache in the absence of a past history of a trauma or a dural puncture [2-5]. Conservative treatment for this condition usually include
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epidural blood patches in a patient with multi level cerebrospinal fluid leakage that was induced by spontaneous intracranial hypotension
The Korean Journal of Pain, 2010Co-Authors: Sae Young Kim, Ji Hee HongAbstract:Spontaneous intracranial hypotension (SIH) is considered to be a very rare disorder. It is characterized by an Orthostatic Headache that is aggravated with the patient in the upright position and it is relieved by the patient assuming the supine position. SIH is caused by a spontaneous spinal cerebrospinal fluid leakage without the patient having undergone trauma, surgery or dural puncture or having any other significant medical history. An autologous epidural blood patch (EBP) is effective in relieving SIH. We report here on a case of SIH with cerebrospinal fluid leakage at the upper cervical vertebral level and the middle thoracic vertebral level. The points of leakage were identified by radionuclide cisternography, and this patient was successfully managed by injecting an EBP at each level of leakage.
