1. Dobrocky T, Nicholson P, Hani L, et al. Spontaneous intracranial hypotension: searching for the CSF leak. [Review]. Lancet Neurology. 21(4):369-380, 2022 04. |
Review/Other-Dx |
N/A |
To discuss the spontaneous intracranial hypotension: searching for the CSF leak. |
No results stated in the abstract. |
4 |
2. Kranz PG, Gray L, Malinzak MD, Amrhein TJ. Spontaneous Intracranial Hypotension: Pathogenesis, Diagnosis, and Treatment. [Review]. Neuroimaging Clin N Am. 29(4):581-594, 2019 Nov. |
Review/Other-Dx |
N/A |
To reviews the clinical presentation and pathogenesis of SIH, discusses the important role of imaging in diagnosis, and describes how imaging guides treatment. |
No results stated in the abstract. |
4 |
3. . Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 38(1):1-211, 2018 01. |
Review/Other-Dx |
N/A |
To review the classifications headache disorders. |
No results stated in the abstract |
4 |
4. D'Antona L, Jaime Merchan MA, Vassiliou A, et al. Clinical Presentation, Investigation Findings, and Treatment Outcomes of Spontaneous Intracranial Hypotension Syndrome: A Systematic Review and Meta-analysis. JAMA Neurology. 78(3):329-337, 2021 03 01. |
Meta-analysis |
6878 articles(53 patients) |
To provide an objective summary of the available evidence on the clinical presentation, investigations findings, and treatment outcomes for SIH. |
Of 6878 articles, 144 met the selection criteria and reported on average 53 patients with SIH each (range, 10-568 patients). The most common symptoms were orthostatic headache (92% [95% CI, 87%-96%]), nausea (54% [95% CI, 46%-62%]), and neck pain/stiffness (43% [95% CI, 32%-53%]). Brain magnetic resonance imaging was the most sensitive investigation, with diffuse pachymeningeal enhancement identified in 73% (95% CI, 67%-80%) of patients. Brain magnetic resonance imaging findings were normal in 19% (95% CI, 13%-24%) of patients. Spinal neuroimaging identified extradural cerebrospinal fluid in 48% to 76% of patients. Digital subtraction myelography and magnetic resonance myelography with intrathecal gadolinium had high sensitivity in identifying the exact leak site. Lumbar puncture opening pressures were low, normal (60-200 mm H2O), and high in 67% (95% CI, 54%-80%), 32% (95% CI, 20%-44%), and 3% (95% CI, 1%-6%), respectively. Conservative treatment was effective in 28% (95% CI, 18%-37%) of patients and a single epidural blood patch was successful in 64% (95% CI, 56%-72%). Large epidural blood patches (>20 mL) had better success rates than small epidural blood patches (77% [95% CI, 63%-91%] and 66% [95% CI, 55%-77%], respectively). |
Good |
5. Schievink WI, Maya MM, Moser F, Tourje J, Torbati S. Frequency of spontaneous intracranial hypotension in the emergency department. J HEADACHE PAIN. 8(6):325-8, 2007 Dec. |
Observational-Dx |
34 patients |
To conduct a study on the frequency of spontaneous intracranial hypotension in the emergency department (ED). |
Eleven patients with previously undiagnosed spontaneous intracranial hypotension were evaluated in the ED during the four-year time period. All patients presented with positional headaches and the duration of symptoms varied from one day to three months. None of the patients were correctly diagnosed with spontaneous intracranial hypotension in the ED. During the same time period, 23 patients with aneurysmal SAH were evaluated. Spontaneous intracranial hypotension is more common than previously appreciated and the diagnosis in the ED remains problematic. |
1 |
6. Kim YJ, Cho HY, Seo DW, et al. Misdiagnosis of Spontaneous Intracranial Hypotension as a Risk Factor for Subdural Hematoma. Headache. 57(10):1593-1600, 2017 Nov. |
Observational-Dx |
128 patients |
To evaluate the association between misdiagnosis of spontaneous intracranial hypotension (SIH) and subdural hematoma development. |
Of the 128 patients with SIH, 111 (86.7%) were in no SDH group and 17 (13.3%) were in SDH group. Their clinical presentation did not show significant different between the two groups, except age, the days from symptom onset to correct diagnosis, and the number of misdiagnoses. Age (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.23) and the number of times SIH was misdiagnosed (OR, 1.82; 95% CI, 1.03-3.21) were independent risk factors for the development of SDH in SIH patients by multivariate logistic analysis. The clinical outcomes, including length of hospital stay and revisit rate, were similar in the two groups. |
2 |
7. Kranz PG, Gray L, Amrhein TJ. Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions. [Review]. Headache. 58(7):948-959, 2018 Jul. |
Review/Other-Dx |
557 studies |
To discuss common myths and misperceptions about spontaneous intracranial hypotension (SIH), focusing on common issues related to diagnosis and treatment, and to review the evidence that contradicts and clarifies these myths. |
Ten topics relevant to diagnosis and treatment SIH were generated by the authors. A search for studies addressing SIH was conducted using PubMed and EMBASE, limited to English language only, peer reviewed publications from inception to 2018. Individual case reports were excluded. The resulting studies were reviewed for relevance to the topics in question. |
4 |
8. Schievink WI. Misdiagnosis of spontaneous intracranial hypotension. Archives of Neurology. 60(12):1713-8, 2003 Dec. |
Review/Other-Dx |
17 patients |
To review the misdiagnosis of spontaneous intracranial hypotension. |
Seventeen patients (94%) initially received an incorrect diagnosis, and the diagnostic delay ranged from 4 days to 13 years (median, 5 weeks; mean, 13 months). Migraine, meningitis, and psychogenic disorder were the most commonly entertained diagnoses. Diagnostic or therapeutic procedures for disorders that mimicked spontaneous intracranial hypotension included cerebral arteriography in 2 patients, craniotomies for Chiari malformation in 2 patients, craniotomy for evacuation of subdural hematomas in 1 patient, and brain biopsy in 1 patient. |
4 |
9. Beck J, Ulrich CT, Fung C, et al. Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension. Neurology. 87(12):1220-6, 2016 Sep 20. |
Observational-Dx |
69 patients |
To visualize and treat spinal dural CSF leaks in all patients with intractable spontaneous intracranial hypotension (SIH) who underwent spinal microsurgical exploration. |
Of 69 consecutive patients, 15 had intractable symptoms. Systematic imaging revealed a suspicious single location of the leak in these 15 patients. Fourteen patients underwent microsurgical exploration; 1 patient refused surgery. Intraoperatively, including intradural exploration, we identified the cause of the CSF leaks as a longitudinal dural slit (6.1 ± 1.7 mm) on the ventral (10), lateral (3), or dorsal (1) aspect of the dura. In 10 patients (71%), a ventral, calcified microspur originating from the intervertebral disk perforated the dura like a knife. Three patients (22%) had a lateral dural tear with an associated spinal meningeal diverticulum, and in 1 patient (7%), a dorsal osteophyte was causal. The microspurs were removed and the dural slits sutured with immediate cessation of CSF leakage. |
2 |
10. Kranz PG, Amrhein TJ, Gray L. Rebound intracranial hypertension: a complication of epidural blood patching for intracranial hypotension. [Review]. Ajnr: American Journal of Neuroradiology. 35(6):1237-40, 2014 Jun. |
Review/Other-Dx |
9 patients |
To review the clinical characteristics of patients with rebound intracranial hypertension, emphasizing factors that can be helpful in discriminating rebound intracranial hypertension from refractory spontaneous intracranial hypotension, and discusses treatment. |
No results stated in the abstract. |
4 |
11. Liu FC, Fuh JL, Wang YF, Wang SJ. Connective tissue disorders in patients with spontaneous intracranial hypotension. Cephalalgia. 31(6):691-5, 2011 Apr. |
Observational-Dx |
55 patients |
To investigate the role of connective tissue disorders in spontaneous intracranial hypotension (SIH) patients. |
The frequencies of joint hypermobility according to Beighton scores >4/9 (SIH 23.6% vs controls 16.4%, P = 0.48) and revised benign joint hypermobility syndrome criteria (SIH 23.6% vs controls 34.5%, P = 0.29) did not differ between SIH patients and controls. Sixteen patients and 16 controls had one or more skin features of EDS (P = 1.0). Nine SIH patients (16.4%) demonstrated the skeletal features of Marfan syndrome; this frequency did not differ from that of the control group (9.1%; P = 0.262). Only dolichostenomelia (disproportionately long limbs) was more prominent in SIH patients than in controls (34.5% vs 9.1%; P = 0.002). |
2 |
12. Schievink WI, Gordon OK, Tourje J. Connective tissue disorders with spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension: a prospective study. Neurosurgery. 54(1):65-70; discussion 70-1, 2004 Jan. |
Observational-Dx |
18 patients |
To estimate the contribution of systemic connective tissue disorders to the development of spontaneous spinal CSF leaks. |
The mean age of the 15 female patients and 3 male patients was 38 years (range, 22-55 yr). Seven patients (38%) demonstrated stigmata of a systemic connective tissue disorder, and three distinct types of disorders could be identified, as follows. 1) The association of spontaneous spinal CSF leaks and minor skeletal features of Marfan syndrome was noted for three patients. 2) Ehlers-Danlos syndrome Type II was noted for two patients. 3) Joint hypermobility associated with marked attenuation of the dorsal muscular fascia, precluding proper wound closure, was noted for two patients. In addition, isolated small-joint hypermobility was observed for five patients (28%). Slit-lamp ocular examinations, echocardiographic evaluations, histopathological examinations of skin biopsy specimens, and renal scanning did not reveal any other features of a systemic connective tissue disorder. |
2 |
13. Amorim JA, Gomes de Barros MV, Valenca MM. Post-dural (post-lumbar) puncture headache: risk factors and clinical features. Cephalalgia. 32(12):916-23, 2012 Sep. |
Observational-Dx |
640 patients |
To evaluate the risk factors of post-dural (post-lumbar) puncture headache (PDPH) and the validity of the diagnostic criteria for PDPH from the ICHD II. |
Forty-eight (7.5%) of the patients developed PDPH. The binary logistic regression analysis identified as risk factors: gender [11.1% female vs. 3.6% male, OR 2.25 (1.07-4.73); p = 0.03], age [11.0% 31-50 years of age vs. 4.2% others, OR 2.21 (1.12-4.36); p = 0.02], previous history of PDPH [26.4% positive vs. 6.2% negative, OR 4.30 (1.99-9.31); p < 0.01] and bevel orientation [16.1% perpendicular vs. 5.7% parallel, OR 2.16 (1.07-4.35); p = 0.03]. The period of latency between lumbar puncture and headache onset range from 6 to 72 hours and the duration from 3 to 15 days. In 34/48 (71%) patients with PDPH, at least one of the following was present: neck stiffness, tinnitus, hypoacusia, photophobia, or nausea. |
1 |
14. DelPizzo K, Cheng J, Dong N, et al. Post-Dural Puncture Headache is Uncommon in Young Ambulatory Surgery Patients. HSS Journal. 13(2):146-151, 2017 Jul. |
Observational-Dx |
300 patients |
To estimate the incidence of PDPH from a 27G pencil-point needle in ambulatory surgery patients between the ages of 15-45 years and compare incidence of PDPH by age group, sex, and history of headache. |
Five patients were excluded from analysis due to complicated operative procedures or spinal needle size. The overall PDPH incidence was 2.0% (95% CI 0.9-4.4; 6/295). PDPH incidence in 15-19-year-old patients was 16.7% (95% CI 4.7-44.8; 2/12). The crude relative risk of PDPH was 15.4 (95% CI 2.8-114.4) for patients with and without history of headache and 2.5 (95% CI 0.5-14.8) for females vs. males. Overall, 16.3% (95% CI 12.5-20.9) of patients reported post-operative, non-positional headaches. |
1 |
15. Philip JT, Flores MA, Beegle RD, Dodson SC, Messina SA, Murray JV. Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index. Ajnr: American Journal of Neuroradiology. 43(2):315-318, 2022 02. |
Observational-Dx |
4435 patients |
To compare epidural blood patch rates between pencil- and bevel-tip needles with a subgroup analysis based on body mass index. |
Postdural puncture headache necessitating an epidural blood patch was statistically more likely using a 22-ga Quincke needle in all patients (P < .001) and overweight (P = .03) and obese (P < .001) populations compared with using a 22-ga pencil-tip Whitacre needle. In the normal body mass index population, there was no statistically significant difference in epidural blood patch rates when using a 22-ga pencil-tip Whitacre needle compared with a 22-ga Quincke needle (P = .12). There was no significant difference in epidural blood patch rates when comparing a 22-ga Quincke needle versus a 20-ga bevel-tip Quincke needle in healthy (P = .70), overweight (P = .69), or obese populations (P = .44). |
2 |
16. Dobrocky T, Grunder L, Breiding PS, et al. Assessing Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension With a Scoring System Based on Brain Magnetic Resonance Imaging Findings. JAMA Neurology. 76(5):580-587, 2019 05 01. |
Observational-Dx |
152 patients |
To develop a probability score based on the most relevant brain MRI findings to assess the likelihood of an underlying spinal cerebrospinal fluid (CSF) leak in patients with SIH. |
A total of 152 participants (101 female [66.4%]; mean [SD] age, 46.1 [14.3] years) were studied. These included 56 with SIH and a spinal CSF leak, 16 with orthostatic headache without a CSF leak, 60 control participants, and 20 patients in the validation cohort. Six imaging findings were included in the final scoring system. Three were weighted as major (2 points each): pachymeningeal enhancement, engorgement of venous sinus, and effacement of the suprasellar cistern of 4.0 mm or less. Three were considered minor (1 point each): subdural fluid collection, effacement of the prepontine cistern of 5.0 mm or less, and mamillopontine distance of 6.5 mm or less. Patients were classified into groups at low, intermediate, or high probability of having a spinal CSF leak, with total scores of 2 points or fewer, 3 to 4 points, and 5 points or more, respectively, on a scale of 9 points. The discriminatory ability of the proposed score could be demonstrated in the validation cohort. |
2 |
17. Mamlouk MD, Shen PY, Sedrak MF, Dillon WP. CT-guided Fibrin Glue Occlusion of Cerebrospinal Fluid-Venous Fistulas. Radiology. 299(2):409-418, 2021 05. |
Review/Other-Dx |
N/A |
To review medical records from two institutions was performed for all patients with CVFs who underwent CT-guided percutaneous fibrin glue occlusion from March to October 2020. |
CT-guided fibrin glue occlusion was performed in 13 patients (mean age, 62 years ± 14 [standard deviation]; eight women) with CVFs. Ten of 10 patients who underwent final posttreatment decubitus CTM examinations showed CVF resolution. All 13 patients showed improvement on posttreatment brain MRI scans. All 13 patients are currently asymptomatic, although three patients were asymptomatic before fibrin glue occlusion. Conclusion CT-guided fibrin glue occlusion is an effective treatment for patients with cerebrospinal fluid-venous fistulas (CVFs). Direct fibrin glue administration within the CVF may be one of the key factors for success. Further studies are needed to determine the long-term efficacy of this treatment. |
4 |
18. Kranz PG, Luetmer PH, Diehn FE, Amrhein TJ, Tanpitukpongse TP, Gray L. Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension. [Review]. AJR. American Journal of Roentgenology. 206(1):8-19, 2016 Jan. |
Review/Other-Dx |
N/A |
To review the imaging of spinal CSF leaks and to assist in the selection of appropriate imaging modalities in this condition. |
No results stated in the abstract |
4 |
19. Schievink WI, Maya MM, Jean-Pierre S, Nuno M, Prasad RS, Moser FG. A classification system of spontaneous spinal CSF leaks. Neurology. 87(7):673-9, 2016 Aug 16. |
Review/Other-Dx |
568 patients |
To review the medical records, radiographic studies, operative notes, and any intraoperative photographs of a group of consecutive patients with spontaneous intracranial hypotension. |
The mean age of the 568 patients (373 [65.7%] women) was 45.7 years. Three types of CSF leak could be identified. Type 1 CSF leaks consisted of a dural tear (151 patients [26.6%]) and these were almost exclusively associated with an extradural CSF collection. Type 1a represented ventral CSF leaks (96%) and type 1b posterolateral CSF leaks (4%). Type 2 CSF leaks consisted of meningeal diverticula (240 patients [42.3%]) and were the source of an extradural CSF collection in 53 of these patients (22.1%). Type 2a represented simple diverticula (90.8%) and type 2b complex meningeal diverticula/dural ectasia (9.2%). Type 3 CSF leaks consisted of direct CSF-venous fistulas (14 patients [2.5%]) and these were not associated with extradural CSF collections. A total of 163 patients (28.7%) had an indeterminate type and extradural CSF collections were noted in 84 (51.5%) of these patients. |
4 |
20. Schievink WI. Spontaneous Intracranial Hypotension. [Review]. New England Journal of Medicine. 385(23):2173-2178, 2021 12 02. |
Review/Other-Dx |
N/A |
To discuss spontaneous Intracranial Hypotension. |
No results stated in the abstract |
4 |
21. Magnaes B. Body position and cerebrospinal fluid pressure. Part 2: clinical studies on orthostatic pressure and the hydrostatic indifferent point. Journal of Neurosurgery. 44(6):698-705, 1976 Jun. |
Observational-Dx |
116 patients |
To discuss the position and cerebrospinal fluid pressure on orthostatic pressure and the hydrostatic indifferent point in 116 adult neurosurgical patients. |
A caudally located ZPS was found in patients with complete cervical subarachnoid block. Prevention and treatment of CSF leakage cranial to HIP is discussed. |
2 |
22. Schievink WI, Schwartz MS, Maya MM, Moser FG, Rozen TD. Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks. Journal of Neurosurgery. 116(4):749-54, 2012 Apr. |
Observational-Dx |
273 patients |
To examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. |
Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. |
2 |
23. Kranz PG, Gray L, Taylor JN. CT-guided epidural blood patching of directly observed or potential leak sites for the targeted treatment of spontaneous intracranial hypotension. AJNR Am J Neuroradiol. 32(5):832-8, 2011 May. |
Observational-Dx |
8 patients |
To evaluate the efficacy of CT-guided blood patching of observed or potential CSF leaks in spontaneous intracranial hypotension. |
Pretreatment imaging findings included dural enhancement, tonsillar ectopia, subdural collections, and syrinx. All findings resolved or significantly improved on posttreatment imaging. Presenting clinical symptoms included positional headache, neck/interscapular/shoulder pain, and tinnitus. Headaches and neck/interscapular/shoulder pain improved in all patients; tinnitus improved in 1 of 2 patients. CSF leak sites were directly visualized in 37% of patients and were targets for patching when seen. When no direct visualization of leaks was seen, irregular spinal nerve root diverticula were targeted as potential leak sites. The average number of blood patching sessions was 3 (range, 1-6) and the average number of individual sites patched per session was 5 (range, 1-10). |
4 |
24. Callen AL, Timpone VM, Schwertner A, et al. Algorithmic Multimodality Approach to Diagnosis and Treatment of Spinal CSF Leak and Venous Fistula in Patients With Spontaneous Intracranial Hypotension. [Review]. AJR. American Journal of Roentgenology. 219(2):292-301, 2022 08. |
Review/Other-Dx |
N/A |
To review imaging techniques including dynamic fluoroscopic and CT myelography as well as delayed MR myelography and treatment options including percutaneous, endovascular, and surgical approaches for Spontaneous intracranial hypotension (SIH). |
No results stated in the abstract. |
4 |
25. Watanabe A, Horikoshi T, Uchida M, Koizumi H, Yagishita T, Kinouchi H. Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neuroradiol. 30(1):147-51, 2009 Jan. |
Observational-Dx |
18 patients |
To elucidate the diagnostic value of brain and spinal MR imaging |
Brain MR imaging detected abnormalities in 15 of the 18 patients (83%): diffuse pachymeningeal enhancement in 15 (83%), descent of the cerebellar tonsil in 13 (72%), brain stem sagging in 13 (72%), enlargement of the pituitary gland in 12 (67%), and subdural fluid collection in 13 (72%). Spinal MR imaging detected abnormalities in 17 of the 18 patients (94%): distention of the epidural veins in 14 (78%), epidural fluid collection on fat-saturated T2-weighted images in 16 (89%), and abnormal visualization of the nerve root sleeve in only 1 (6%). The sensitivity for SIH was 83% for brain MR imaging and 94% for spinal MR imaging. |
2 |
26. Chen ST, Wu JW, Wang YF, Lirng JF, Hseu SS, Wang SJ. The time sequence of brain MRI findings in spontaneous intracranial hypotension. Cephalalgia. 42(1):12-19, 2022 01. |
Observational-Dx |
173 patients |
To investigate the time sequence of brain magnetic resonance imaging findings of spontaneous intracranial hypotension. |
A total of 173 patients (57 males and 116 females) were included in the analysis, and the range of onset-neuroimaging interval was 1 to 89 days (median [interquartile range] = 17 [7 to 30 days]). We divided the patients into quartiles based on their onset-neuroimaging interval (the first quartile: 0-6 days; the second quartile: 7-16 days; the third quartile: 17-29 days; the fourth quartile: =30 days). Among brain magnetic resonance imaging findings, the incidence of venous distension sign was high (>75%), with no difference among quartiles (p = 0.876). The incidence of diffuse pachymeningeal enhancement (p = 0.001), severe midbrain-pons deformity (p = 0.001), and subdural fluid collection (<0.001) followed a significant stepwise increase from the first quartile to fourth quartile. Patients with shorter onset-neuroimaging intervals were less likely to have neuroimaging scores =5 (<17 vs. =17 days: 72.9% vs. 86.4%; odds ratio = 2.3 [95% CI 1.1-5.1], p = 0.028), but not neuroimaging scores =3 (<17 vs. =17 days: 92.9% vs. 92.0%, p = 0.824). |
2 |
27. Schievink WI, Maya M, Moser F, Nuno M. Long-term Risks of Persistent Ventral Spinal CSF Leaks in SIH: Superficial Siderosis and Bibrachial Amyotrophy. Neurology. 97(19):e1964-e1970, 2021 11 09. |
Observational-Dx |
51 patients |
To determine the risk of these serious complications of persistent ventral spinal CSF leaks. |
Among 51 patients with SIH and a persistent ventral spinal CSF leak, superficial siderosis developed in 6 patients and bibrachial amyotrophy in 2 patients during 280 patient-years of follow-up. The probability of these complications increased from 0% at 48 months to 4.5% (95% confidence interval [CI] 1.0%-28.0%) at 56 months, 10.5% (95% CI 3.0%-36.4%) at 96 months, 32.7% (95% CI 15.0%-62.8%) at 144 months, and 57.9% (95% CI 30.2%-87.6%) at 192 months. None of the patients developed spinal cord herniation. |
2 |
28. Medina JH, Abrams K, Falcone S, Bhatia RG. Spinal imaging findings in spontaneous intracranial hypotension. AJR Am J Roentgenol. 195(2):459-64, 2010 Aug. |
Review/Other-Dx |
13 patients |
To review and describe the spinal imaging findings of the spontaneous intracranial hypotension. |
The patients were found to have spinal fluid collections (11 of 13 patients), dural enhancement (eight of 10 patients undergoing contrast administration), dilated epidural veins (10 of 13 patients), an enlarged epidural venous plexus (nine of 13 patients), C1-C2 sign (seven of 13 patients), structural abnormalities (four of 13 patients), canal attenuation or cord compression (five of 13 patients), and active contrast extravasation (four of 13 patients). |
4 |
29. Dillon WP. Spinal manifestations of intracranial hypotension. Ajnr: American Journal of Neuroradiology. 22(7):1233-4, 2001 Aug. |
Review/Other-Dx |
N/A |
To discuss the Spinal manifestations of intracranial hypotension. |
No results stated in the abstract. |
4 |
30. Kranz PG, Amrhein TJ, Gray L. CSF Venous Fistulas in Spontaneous Intracranial Hypotension: Imaging Characteristics on Dynamic and CT Myelography. AJR. American Journal of Roentgenology. 209(6):1360-1366, 2017 Dec. |
Observational-Dx |
22 patients |
To describe the anatomic and imaging features of CSF venous fistulas, which are a recently reported cause of spontaneous intracranial hypotension (SIH). |
Twenty-two cases of CSF venous fistula were identified. The fistulas were located between T4 and L1. Ninety percent occurred without a concurrent epidural CSF leak. In most cases (82%), the CSF venous fistula originated from a nerve root sleeve diverticulum. On CTM, the abnormal veins associated with the CSF venous fistula were seen in a paravertebral location in 45% of cases, centrally within the epidural venous plexus in 32%, and lateral to the spine in 23%. Differences in attenuation between the fistula veins and the control veins was highly statistically significant (p < 0.0001), with a threshold of 70 HU perfectly discriminating fistulas from normal veins in our series. When both CTM and dynamic myelography were performed, the fistula was identified on both modalities in 88% of cases. |
4 |
31. Kranz PG, Tanpitukpongse TP, Choudhury KR, Amrhein TJ, Gray L. How common is normal cerebrospinal fluid pressure in spontaneous intracranial hypotension?. Cephalalgia. 36(13):1209-1217, 2016 Nov. |
Observational-Dx |
106 patients |
To determine the proportion of patients with spontaneous intracranial hypotension (SIH) who had a cerebrospinal fluid (CSF) pressure >6 cm H2O and to investigate the clinical and imaging variables associated with CSF pressure ( PCSF) in this condition |
Sixty-one percent of patients had a PCSF between 6 and 20 cm H2O; only 34% had a PCSF =6 cm H2O. The factors associated with increased PCSF included abdominal circumference ( p < 0.001), symptom duration ( p = 0.015), and the absence of brain magnetic resonance imaging findings of SIH ( p = 0.003). A wide variability in PCSF was observed among all patients, which was not completely accounted for by the variables included in the model. Conclusions Normal CSF pressure is common in patients with SIH; the absence of a low opening pressure should not exclude this condition. Body habitus, symptom duration, and brain imaging are correlated with PCSF measurements, but these factors alone do not entirely explain the wide variability in observed pressures in this condition and this suggests the influence of other factors. |
4 |
32. Callen AL, Pattee J, Thaker AA, et al. Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial Hypotension. Neurology. 100(22):e2237-e2246, 2023 05 30. |
Observational-Dx |
53 patients |
To investigate whether evaluation of brain MRI using the Bern score, combined with calculated craniospinal elastance, would aid in diagnosing spontaneous intracranial hypotension (SIH) and provide insight into its pathophysiology. |
Seventy-two consecutive dCTMs were performed in 53 patients. Twelve CSF-venous fistulae, 2 ruptured meningeal diverticula, 2 dural defects, and 1 dural bleb were found (17/53, 32%). Among patients with imaging-proven CSF leak/fistula, OP was normal in all but 1 patient and was not significantly different in those with a leak compared with those without (15.1 vs 13.6 cm H2O, p = 0.24, A = 0.40). The average Bern score in individuals with a leak was significantly higher than that in those without (5.35 vs 1.85, p < 0.001, A = 0.85), even when excluding pachymeningeal enhancement from the score (3.77 vs 1.57, p = 0.001, A = 0.78). The average elastance in those with a leak was higher than that in those without, but this difference was not statistically significant (2.05 vs 1.20 mL/cm H2O, p = 0.19, A = 0.40). Increased elastance was significantly associated with an increased Bern score (95% CI -0.55 to 0.12, p < 0.01) and was significantly associated with venous distention, pachymeningeal enhancement, prepontine narrowing, and subdural collections, but not a narrowed mamillopontine or suprasellar distance. |
2 |
33. Bond KM, Benson JC, Cutsforth-Gregory JK, Kim DK, Diehn FE, Carr CM. Spontaneous Intracranial Hypotension: Atypical Radiologic Appearances, Imaging Mimickers, and Clinical Look-Alikes. [Review]. AJNR Am J Neuroradiol. 41(8):1339-1347, 2020 08. |
Review/Other-Dx |
N/A |
To discuss conditions that mimic the radiologic and clinical presentation of spontaneous intracranial hypotension as well as other disorders that CSF leaks can imitate |
No results stated in the abstract. |
4 |
34. Wang YF, Lirng JF, Fuh JL, Hseu SS, Wang SJ. Heavily T2-weighted MR myelography vs CT myelography in spontaneous intracranial hypotension. Neurology. 73(22):1892-8, 2009 Dec 01. |
Observational-Dx |
19 patients |
To assess the diagnostic accuracy of heavily T2-weighted magnetic resonance myelography (MRM) in patients with spontaneous intracranial hypotension (SIH). |
Nineteen patients (6 men and 13 women, mean age 37.9 +/- 8.6 years) with SIH completed the study. MRM did not differ from CTM in the detection rates of CSF leaks along the nerve roots (84% vs 74%, p = 0.23), high-cervical retrospinal CSF collections (32% vs 16%, p = 0.13), and epidural CSF collections (89% vs 79%, p = 0.20). MRM demonstrated more spinal levels of CSF leaks (2.2 +/- 1.7 vs 1.5 +/- 1.5, p = 0.011) and epidural collections (12.2 +/- 5.9 vs 7.1 +/- 5.8, p < 0.001) than CTM. The overall level-by-level concordance was substantial for CSF leaks along the nerve roots (C1-L3) (kappa = 0.71, p < 0.001, agreement = 95%) and high-cervical retrospinal CSF collections (C1-3) (kappa = 0.73, p < 0.001, agreement = 92%), and moderate for epidural CSF collections (C1-L3) (kappa = 0.47, p < 0.001, agreement = 72%). Ten of the 14 patients (71%) receiving targeted EBPs experienced sustained symptomatic relief after a single attempt. |
2 |
35. Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Utility of heavily T2-weighted MR myelography as the first step in CSF leak detection and the planning of epidural blood patches. Journal of Clinical Neuroscience. 77:110-115, 2020 Jul. |
Observational-Dx |
26 patients |
To to assess epidural blood patch (EBP) treatment outcome when using HT2W-MRM as the primary modality for detecting CSF leak and planning EBP placement in routine clinical practice. |
Since 2018, patients at our institute suspected of having CSF leak, routinely HT2W-MRM instead of CT myelography to determine presence of the leak and identify the EBP target site. Fifty-nine consecutive patients suspected of having a CSF leak underwent HT2W-MRM. After excluding patients with subdural hematoma and poor image quality, 26 (10 men, 16 women; mean age 44.92 ± 12.6 years) patients were included in this study. Patients received EBP on the basis of HT2W-MRM assessments and clinical assessment. Imaging findings and clinical outcome were evaluated. CSF leak was identified in 21 patients (80.8%, 21/26) based HT2W-MRM. Most cases were graded on a confidence scale as CSF leak definitely (n = 13) or probably (n = 3) present. Successful clinical EBP treatment was achieved in 14 of 17 patients (82.4%) after first targeted EBP, and patient symptoms significantly improved after treatment (numerical rating score 6.4 before EBP, 1.3 after EBP, P < 0.001). HT2W-MRM based EBP are the rational and effective choices for CSF leak treatment in routine clinical practice. |
2 |
36. Starling A, Hernandez F, Hoxworth JM, et al. Sensitivity of MRI of the spine compared with CT myelography in orthostatic headache with CSF leak. Neurology. 81(20):1789-92, 2013 Nov 12. |
Observational-Dx |
12 patients |
To investigate the sensitivity of magnetic resonance imaging (MRI) of the spine compared with computed tomography (CT) myelography (CTM) in detecting cerebro spinal fluid (CSF) leaks |
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. |
3 |
37. Caton MT Jr, Laguna B, Soderlund KA, Dillon WP, Shah VN. Spinal Compliance Curves: Preliminary Experience with a New Tool for Evaluating Suspected CSF Venous Fistulas on CT Myelography in Patients with Spontaneous Intracranial Hypotension. Ajnr: American Journal of Neuroradiology. 42(5):986-992, 2021 05. |
Observational-Dx |
22 patients |
To describe a method to estimate craniospinal space compliance using saline infusion during CT myelography and explores the use of craniospinal space compliance and pressure-volume curves in patients with suspected cerebrospinal-venous fistula. |
Thirty-four CT myelograms in 22 patients were analyzed. Eight of 22 (36.4%) patients had confirmed cerebrospinal-venous fistulas. Bolus infusion was well-tolerated with no complications and transient headache in 2/34 (5.8%). Patients with confirmed cerebrospinal-venous fistulas had higher compliance at opening pressure and overall compliance (2.6 versus 1.8 mL/cm H20, P < .01). There was no difference in the pressure volume index (77.5 versus 54.3 mL, P = .13) between groups. |
2 |
38. Dobrocky T, Mosimann PJ, Zibold F, et al. Cryptogenic Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension: Role of Dynamic CT Myelography. Radiology. 289(3):766-772, 2018 12. |
Observational-Dx |
14 patients |
To propose a modified dynamic CT myelographic technique to locate cerebrospinal fluid (CSF) leaks, also known as cryptogenic leaks, in patients with spontaneous intracranial hypotension (SIH) in whom previous imaging did not show the dural breach. |
Mean population age was 44 years (range, 25-65 years [nine women; mean age, 44 years; age range, 25-65 years] [five men; mean age, 46 years; age range, 29-61 years]). All patients had previously undergone spine MRI, conventional dynamic myelography, and CT myelography. Subsequent dynamic CT myelography covered a mean range of seven vertebral levels. The leak was caused by a calcified microspur in 10 patients and by a dural tear at the axilla of a spinal nerve root in the remaining four. The mean volume CT dose index of dynamic CT myelography was 107 mGy (range, 12-246 mGy), and the mean dose-length product was 1347 mGy·cm (range, 550-3750 mGy·cm) |
2 |
39. Madhavan AA, Verdoorn JT, Shlapak DP, et al. Lateral decubitus dynamic CT myelography for fast cerebrospinal fluid leak localization. Neuroradiology. 64(9):1897-1903, 2022 Sep. |
Observational-Dx |
6 patients |
To determine the added value of lateral decubitus dynamic CT myelography, which is occasionally attempted in our practice, in localizing the leak after failed prone dynamic CT myelography |
No results stated in the abstract. |
2 |
40. Mamlouk MD, Ochi RP, Jun P, Shen PY. Decubitus CT Myelography for CSF-Venous Fistulas: A Procedural Approach. Ajnr: American Journal of Neuroradiology. 42(1):32-36, 2021 01. |
Review/Other-Dx |
22 patients |
To discuss the procedural approach of the decubitus CT Myelography for CSF-Venous Fistulas. |
No results stated in the abstract |
4 |
41. Kim DK, Brinjikji W, Morris PP, et al. Lateral Decubitus Digital Subtraction Myelography: Tips, Tricks, and Pitfalls. [Review]. Ajnr: American Journal of Neuroradiology. 41(1):21-28, 2020 01. |
Review/Other-Dx |
N/A |
To discuss Tips, Tricks, and Pitfalls of Tips, Tricks, and Pitfalls. |
No results stated in the abstract. |
4 |
42. Schievink WI, Maya MM, Moser FG, et al. Lateral decubitus digital subtraction myelography to identify spinal CSF-venous fistulas in spontaneous intracranial hypotension. Journal of Neurosurgery Spine. 1-4, 2019 Sep 13. |
Observational-Dx |
23 patients |
To compared findings of digital subtraction myelography (DSM) with patients in the lateral decubitus position versus the prone position and now report a significantly increased yield of identifying spinal CSF-venous fistulas with this modification of their imaging protocol. |
A CSF-venous fistula was demonstrated in 17 (74%) of the 23 patients who underwent DSM in the lateral decubitus position compared to 4 (15%) of the 26 patients who underwent DSM in the prone position (p < 0.0001). The mean age of these 16 women and 5 men was 52.5 years (range 36-66 years). |
2 |
43. Shlapak DP, Mark IT, Kim DK, et al. Incremental diagnostic yield and clinical outcomes of lateral decubitus CT myelogram immediately following negative lateral decubitus digital subtraction myelogram. Neuroradiology Journal. 36(5):593-600, 2023 Oct. |
Review/Other-Dx |
83 patients |
To evaluate the incremental diagnostic yield of lateral decubitus CT myelogram (LDCTM) following negative DSM and reviewed patient outcomes. |
Of the 83 patients with negative DSMs, 11 (13.2%) had positive leak findings on LDCTMs, and 21 (25.3%) were equivocal. Of 11 positive LDCTMs, 6 leaks were nerve sheath tears (NSTs) and 5 were CSF-venous fistulas (CVFs). 10/11 (90.9%) had intervention and follow-up, with 9/10 (90%) having positive clinical outcome. Of the 21 equivocal LDCTM patients (19 CVFs and 2 NSTs), 15 (71.4%) had interventions and follow-up, with 3/15 (20.0%) with positive clinical outcomes. |
4 |
44. Carlton Jones L, Goadsby PJ. Same-Day Bilateral Decubitus CT Myelography for Detecting CSF-Venous Fistulas in Spontaneous Intracranial Hypotension. Ajnr: American Journal of Neuroradiology. 43(4):645-648, 2022 04. |
Review/Other-Dx |
3 patients |
To report on the feasibility of obtaining diagnostic-quality bilateral decubitus CT myelography in a single session, avoiding the need to schedule separate examinations for the left and right sides on different days. |
No results stated in the abstract. |
4 |
45. Monteith TS, Kralik SF, Dillon WP, Hawkins RA, Goadsby PJ. The utility of radioisotope cisternography in low CSF/volume syndromes compared to myelography. Cephalalgia. 36(13):1291-1295, 2016 Nov. |
Review/Other-Dx |
12 patients |
To compare computed tomography (CT) and magnetic resonance (MR) myelography with radioisotope cisternography (RC) for detection of spinal cerebrospinal (CSF) leaks |
CT and/or MR myelography identified CSF leaks in four of 12 patients. RC detected spinal leaks in all three patients confirmed by CT myelography; RC identified the CSF leak location in two of three cases, and these were due to osteophytic spicules and/or discs. RC showed only enlarged perineural activity. Only intrathecal gadolinium MR myelography clearly identified a slow leak from a perineural cyst. In eight remaining cases, the leak site was unknown; however, two of these showed indirect signs of CSF leak on RC. CSF slow leaks from perineural cysts were the most common presumed etiology; and the cysts were best visualized on myelography. Conclusion RC is comparable to CT myelography but has spatial limitations and should be limited to atypical cases. |
4 |
46. Sakurai K, Nishio M, Yamada K, et al. Comparison of the radioisotope cisternography findings of spontaneous intracranial hypotension and iatrogenic cerebrospinal fluid leakage focusing on chronological changes. Cephalalgia. 32(15):1131-9, 2012 Nov. |
Observational-Dx |
13 patients |
To compare the Radioisotope cisternography (RICG) findings of spontaneous intracranial hypotension (SIH) and iatrogenic CSF leakage (ICSFL). |
In contrast to the variety of anatomical levels at which direct findings were detected in the SIH patients, the ICSFL patients only displayed direct findings at the lumbosacral level. None of the ICSFL patients displayed direct findings at 1 hour after the tracer injection. Although early visualization of the bladder was depicted in all patients, no activity was visualized over the brain convexities in the SIH patients. In the semi-quantitative analysis, the tracer retention index at 24 hours was lower in the SIH patients than the ICSFL patients. |
2 |
47. Madhavan AA, Carr CM, Benson JC, et al. Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization. Clinical Neuroradiology. 32(2):537-545, 2022 Jun. |
Review/Other-Dx |
97 patients |
To determine the diagnostic yield of MR myelography in patients with spontaneous intracranial hypotension. |
A total of 97 patients were included in the final cohort. The average age was 52.6 years; 67.0% were female, 4 patients underwent 2 examinations each, yielding a total of 101 MR myelograms. The source of a spinal CSF leak was localized in 14 patients. The diagnostic yield for CSF leak localization on intrathecal gadolinium MR myelography was 14/101 (13.9%) per GdM examination and 14/97 (14.4%) per patient. Among the subset of patients without extradural fluid collections, the yield was 15.7% per examination. All detected leaks were either CSF-venous fistulas or distal nerve root sleeve tears. |
4 |
48. Akbar JJ, Luetmer PH, Schwartz KM, Hunt CH, Diehn FE, Eckel LJ. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. AJNR Am J Neuroradiol. 33(3):535-40, 2012 Mar. |
Review/Other-Dx |
41 patients |
To determine whether GdM was helpful in confirming and localizing spinal CSF leaks in patients in whom no leak was identified on a prior CTM. |
In 17 of the 41 patients (41%), GdM was performed for follow-up of a previously documented leak at CTM. In the remaining 24 patients (59%), in whom GdM was performed for a suspected CSF leak, which was not identified on CTM, GdM localized the CSF leak in 5 of 24 patients (21%). In 1 of these 5 patients, GdM detected the site of leak despite negative findings on brain MR imaging, spine MR imaging, and CTM of the entire spine. Sixteen of 17 patients with previously identified leaks underwent interval treatment, and leaks were again identified in 12 of 17 (71%). |
4 |
49. Chazen JL, Talbott JF, Lantos JE, Dillon WP. MR myelography for identification of spinal CSF leak in spontaneous intracranial hypotension. Ajnr: American Journal of Neuroradiology. 35(10):2007-12, 2014 Oct. |
Observational-Dx |
24 patients |
To evaluate the additional benefits of intrathecal gadolinium MR myelography in the detection of CSF leak. |
Twenty-four patients met both imaging and clinical criteria for spontaneous intracranial hypotension and underwent CT myelography followed by intrathecal gadolinium MR myelography. In 3/24 patients (13%), a CSF leak was demonstrated on both CT myelography and intrathecal gadolinium MR myelography, and in 9/24 patients (38%), a CSF leak was seen on intrathecal gadolinium MR myelography (P = .011). Four of 6 leaks identified independently by intrathecal gadolinium MR myelography related to meningeal diverticula. CT myelography did not identify any leaks independently. There were no reported adverse events. |
2 |
50. Chazen JL, Robbins MS, Strauss SB, Schweitzer AD, Greenfield JP. MR Myelography for the Detection of CSF-Venous Fistulas. Ajnr: American Journal of Neuroradiology. 41(5):938-940, 2020 05. |
Review/Other-Dx |
3 patients |
To describe the technical aspects and diagnostic performance of MR myelography when used for identifying CSF-venous fistulas. To report 3 cases in which the CSF-venous fistula was occult on CT myelography but readily detected using MR myelography. |
No results stated in the abstract. |
4 |
51. Patel M, Atyani A, Salameh JP, McInnes M, Chakraborty S. Safety of Intrathecal Administration of Gadolinium-based Contrast Agents: A Systematic Review and Meta-Analysis. Radiology. 297(1):75-83, 2020 Oct. |
Review/Other-Dx |
53 studies |
To perform a systematic review to establish an understanding of the dose-response relationship of intrathecal GBCAs and to characterize related adverse events, particularly at higher doses |
Fifty-three studies with a total of 1036 patients were included for analysis. The overall rate of adverse events after intrathecal administration of GBCA was 13% (95% confidence interval [CI]: 9.3%, 18%). Meta-analysis revealed moderate heterogeneity (I2 = 62%). Serious adverse event rates could not be determined with meta-analysis. They were reported in 10 studies and were primarily neurologic in nature, with two cases of coma-one resulting in death. Serious adverse events were associated with significantly higher GBCA doses when compared with nonserious adverse events (mean difference, 4.5 mmol; 95% CI: 2.3 mmol, 6.6 mmol; P = .008). For serious adverse events, there was no clear dose-dependent increase in severity above 2.0 mmol. Conclusion Overall, intrathecal administration of GBCAs at doses greater than 1.0 mmol are associated with serious neurotoxic complications with relative clinical safety at lower doses. |
4 |
52. Dobrocky T, Winklehner A, Breiding PS, et al. Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences. Ajnr: American Journal of Neuroradiology. 41(7):1309-1315, 2020 07. |
Observational-Dx |
103 patients |
To compare the diagnostic accuracy of unenhanced spine MR imaging and intrathecal gadolinium-enhanced spine MR imaging for identification and localization of CSF leaks in patients with spontaneous intracranial hypotension. |
In total, 103 patients with spontaneous intracranial hypotension (63/103 [61%] women; mean age, 50 years) were evaluated. Seventy had a confirmed CSF leak (57/70 [81%] proved intraoperatively), and 33 showed no epidural CSF on multimodal imaging. Intrathecal gadolinium-enhanced spine MR imaging was nonsuperior to unenhanced spine MR imaging for the detection of epidural CSF (P = .24 and .97). All MR imaging sequences had a low accuracy for leak localization. In all patients, only 1 leakage point was present, albeit multiple suspicious lesions were reported in all sequences (mean, 5.0). |
2 |
53. Schievink WI, Maya M, Prasad RS, et al. Spontaneous spinal cerebrospinal fluid-venous fistulas in patients with orthostatic headaches and normal conventional brain and spine imaging. Headache. 61(2):387-391, 2021 02. |
Observational-Dx |
60 patients |
To determine the occurrence of cerebrospinal fluid (CSF)-venous fistulas, a type of spinal CSF leak that cannot be detected with routine computerized tomography myelography, among patients with orthostatic headaches but normal brain and spine magnetic resonance imaging. |
The mean age of the 60 consecutive patients (46 women and 14 men) was 46 years (range, 13-83 years), who had been suffering from orthostatic headaches between 1 and 180 months (mean, 43 months). DSM demonstrated a spinal CSF-venous fistula in 6 (10.0%; 95% confidence interval [CI]: 3.8-20.5%) of the 60 patients. The mean age of these five women and one man was 50 years (range, 41-59 years). Spinal CSF-venous fistulas were identified in 6 (19.4%; 95% CI: 7.5-37.5%) of 31 patients with spinal meningeal diverticula but in none (0%; 95% CI: 0-11.9%) of the 29 patients without spinal meningeal diverticula (p = 0.024). All CSF-venous fistulas were located in the thoracic spine. All patients underwent uneventful surgical ligation of the fistula. Complete and sustained resolution of symptoms was obtained in five patients, while in one patient, partial recurrence of symptoms was noted 3 months postoperatively. |
2 |
54. Schievink WI, Moser FG, Maya MM, Prasad RS. Digital subtraction myelography for the identification of spontaneous spinal CSF-venous fistulas. Journal of Neurosurgery Spine. 24(6):960-4, 2016 Jun. |
Review/Other-Dx |
53 patients |
To report on the use of digital subtraction myelography in patients with spontaneous intracranial hypotension but no CSF leak identifiable on conventional spinal imaging (i.e., non-digital subtraction myelography). |
The mean age of the 33 women and 20 men was 53.4 years (range 29-71 years). A CSF-venous fistula was demonstrated in 10 (19%) of the 53 patients. A CSF-venous fistula was found in 9 (27%) of the 33 women and in 1 (5%) of the 20 men (p = 0.0697). One patient was treated successfully with percutaneous injection of fibrin sealant. Nine patients underwent surgery for the fistula. Surgery resulted in complete resolution of symptoms in 8 patients (follow-up 7-25 months), and in 1 patient, symptoms recurred after 4 months. CONCLUSIONS In this study, the authors found a CSF-venous fistula in approximately one-fifth of the patients with recalcitrant spontaneous intracranial hypotension but no CSF leak identifiable on conventional spinal imaging. The authors suggest that digital subtraction myelography be considered in this patient population. |
4 |
55. Flaatten H, Thorsen T, Askeland B, et al. Puncture technique and postural postdural puncture headache. A randomised, double-blind study comparing transverse and parallel puncture. Acta Anaesthesiologica Scandinavica. 42(10):1209-14, 1998 Nov. |
Observational-Dx |
212 patients |
To investigate the effect of two different orientations of the bevel during dural puncture on development of postural postdural puncture headache (PPDPH). |
Two hundred and twelve patients with a mean age of 35.3 years completed the study, 106 in each group. The two groups were comparable with regard to mean age, sex, local anaesthetics used and surgical procedure performed. Headache occurred in 44 patients postoperatively. PPDPH was diagnosed in 4/106 patients (3.8%) in the parallel group and 24/106 (22.6%) in the transverse group (P < 0.0002). Postoperative backache occurred in 31 and 20 patients (parallel compared to transverse) (NS). |
2 |
56. Zorrilla-Vaca A, Makkar JK. Effectiveness of Lateral Decubitus Position for Preventing Post-Dural Puncture Headache: A Meta-Analysis. Pain Physician. 20(4):E521-E529, 2017 05. |
Meta-analysis |
7 articles (1,101 patients) |
To hypothesize that lateral decubitus position is an effective manner to prophylactically reduce the incidence of Post-dural puncture headache (PDPH). |
Literature search identified 7 eligible RCTs (6 on spinal anesthesia and only one on neurologic diagnosis) with 1,101 patients, of which 557 had lumbar punctures in lateral decubitus position and 544 in sitting position. Only 3 (out of 7) RCTs favored the lateral decubitus position to significantly reduce the PDPH. Meta-analysis showed that the lateral decubitus position was associated with a significant reduction of the incidence of PDPH (risk ratio [RR] = 0.61, 95% confidence interval [CI] = 0.44-0.86, P = 0.004, I2 = 25%, P for heterogeneity = 0.24) compared with the sitting position. Subgroup analysis showed that lateral decubitus position is also associated with reduction of PDPH in spinal anesthesia (RR = 0.69, 95% CI = 0.50-0.95, I2 = 0%, P for heterogeneity = 0.42). We found no statistically significant association between lateral decubitus position and successful placement of spinal needle at first attempt (RR = 1.00, 95% CI = 0.92-1.09, P = 0.94, I2 = 73%, P for heterogeneity = 0.01). There was no evidence of publication bias in our analyses (Egger's bias = -0.05, P = 0.96). |
Good |
57. Seeberger MD, Kaufmann M, Staender S, Schneider M, Scheidegger D. Repeated dural punctures increase the incidence of postdural puncture headache. Anesth Analg 1996;82:302-5. |
Observational-Dx |
N/A |
To hypothesize that insufficient statistical power of these studies was the cause for this unexpected finding, and re-examined whether repeated dural punctures increase the incidence of PDPH by analyzing prospectively collected data on 8034 spinal anesthetics. |
No results stated in the abstract. |
2 |
58. Zorrilla-Vaca A, Mathur V, Wu CL, Grant MC. The Impact of Spinal Needle Selection on Postdural Puncture Headache: A Meta-Analysis and Metaregression of Randomized Studies. Regional Anesthesia & Pain Medicine. 43(5):502-508, 2018 Jul. |
Meta-analysis |
57 articles |
To examine the association between spinal needle characteristics and incidence of postdural puncture headache (PDPH). |
Fifty-seven randomized controlled trials (n = 16416) were included in our analysis, of which 32 compared pencil-point design with cutting-needle design and 25 compared individual gauges of similar design. Pencil-point design was associated with a statistically significant reduction in incidence of PDPH (risk ratio, 0.41; 95% confidence interval, 0.31-0.54; P < 0.001; I = 29%) compared with cutting needles among studies that assessed both design types. Subgroup analysis among obstetric and nonobstetric procedures yielded similar results. After adjustment for significant covariates, metaregression analysis among all 57 included trials revealed a significant correlation between needle gauge and rate of PDPH among cutting needles (slope = -2.65, P < 0.001), but not pencil-point needles (slope = -0.01, P = 0.819). |
Good |
59. Booth JL, Pan PH, Thomas JA, Harris LC, D'Angelo R. A retrospective review of an epidural blood patch database: the incidence of epidural blood patch associated with obstetric neuraxial anesthetic techniques and the effect of blood volume on efficacy. International Journal of Obstetric Anesthesia. 29:10-17, 2017 Feb. |
Review/Other-Dx |
394 patients |
To retrospectively review epidural blood patch and delivery statistics over a 15-year period to determine if the volume of blood administered during the procedure directly correlated with the number of epidural blood patches administered |
There were 466 epidural blood patches performed on 394 patients, associated with 84 804 obstetric neuraxial procedures. Thirty-two percent (95% CI 28.3 to 34.9%) of patients who had an inadvertent dural puncture with an epidural needle received an epidural blood patch versus 0.19% (0.16% to 0.22%) of patients who received neuraxial anesthesia with no documented dural puncture with an epidural needle. All patients experienced relief of post-dural puncture headache, although 17% required two and 1.5% required three epidural blood patches. The mean±SD volume of blood administered was 20.5±5.4mL and only 35 patients (8.9%) received 30mL. |
4 |
60. Safa-Tisseront V, Thormann F, Malassine P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology. 95(2):334-9, 2001 Aug. |
Observational-Dx |
504 patients |
To assess both the effectiveness and the predictive factors of failure of Lumbar epidural blood patch (EBP) on severe post-dural puncture headache. |
A total of 504 patients were analyzed. The frequency rates of complete relief, incomplete relief of symptoms, and failure after EBP were 75% (n = 377), 18% (n = 93), and 7% (n = 34), respectively. In a multivariate analysis, only the diameter of the needle used to perform dura mater puncture (odds ratio = 5.96; 95% confidence interval, 2.63-13.47; P < 0.001) and a delay in EBP less than 4 days (odds ratio = 2.63; 95% confidence interval, 1.06-6.51; P = 0.037) were independent significant risk factors for a failure of EBP. |
2 |
61. American Society of Anesthesiologists. Statement on Post-Dural Puncture Headache Management. Available at: https://www.asahq.org/standards-and-guidelines/statement-on-post-dural-puncture-headache-management. |
Review/Other-Dx |
N/A |
Statement on post-dural puncture headache management. |
No abstract available. |
4 |
62. Idrissi AL, Lacour JC, Klein O, Schmitt E, Ducrocq X, Richard S. Spontaneous Intracranial Hypotension: Characteristics of the Serious Form in a Series of 24 Patients. World Neurosurgery. 84(6):1613-20, 2015 Dec. |
Observational-Dx |
24 patients |
To review 24 cases of patients with SIH and separated them into 2 groups according to whether or not they presented with signs of severity at admission: disturbance of consciousness, subdural hematomas (SDHs), and cerebral venous thrombosis. |
Nine patients (37%) were classified as having a serious form of SIH: six (25%) presented SDHs; three (12%) disturbance of consciousness; and one (4%) cerebral venous thrombosis. Bed rest and epidural blood patches (EBPs) were sufficient to treat all patients in the nonserious form group and 4 patients in the serious form group. Two patients (8%) had to undergo cerebrospinal fluid leak repair, and 3 others (12%) evacuation of SDHs. Outcome was good in both groups, with only one (4%) death due to extensive SDHs. Times to diagnosis in the serious form group (63 vs. 35 days, P = 0.052) and to recovery (9 months vs. 5 months, P = 0.088) tended to be higher without reaching difference. |
2 |
63. Schievink WI, Maya MM, Moser FG, Jean-Pierre S, Nuno M. Coma: A serious complication of spontaneous intracranial hypotension. Neurology. 90(19):e1638-e1645, 2018 05 08. |
Review/Other-Dx |
15 patients |
To review our experience with patients with spontaneous intracranial hypotension (SIH) and coma because, although disorders of consciousness may complicate SIH, no comprehensive study of such patients has been reported. |
The mean age of the 12 men and 3 women with SIH was 56.2 years (range 34-72 years) at the time of onset of coma. In one-third of patients, coma developed after craniotomy for subdural hematomas or for an unrelated intracranial pathology. Imaging showed brain sagging, including bilateral temporal lobe herniation, in all 15 patients and brainstem edema in 8 patients (53%). Overall, coma was reversible in 7 of 15 patients treated with epidural blood patches, in 2 of 4 treated with percutaneous glue injections, and in 6 of 6 treated surgically. Only 1 patient had residual neurologic deficit related to coma (Glasgow Outcome Scale score 4 [moderate disability]). Compared to patients with SIH without coma (n = 568), those with coma were older, more often were male, and more often underwent surgery. |
4 |
64. Muram S, Yavin D, DuPlessis S. Intrathecal Saline Infusion as an Effective Temporizing Measure in the Management of Spontaneous Intracranial Hypotension. World Neurosurg. 125:37-41, 2019 05. |
Review/Other-Dx |
12 patients |
To compare computed tomography (CT) and magnetic resonance (MR) myelography with radioisotope cisternography (RC) for detection of spinal cerebrospinal (CSF) leaks. |
CT and/or MR myelography identified CSF leaks in four of 12 patients. RC detected spinal leaks in all three patients confirmed by CT myelography; RC identified the CSF leak location in two of three cases, and these were due to osteophytic spicules and/or discs. RC showed only enlarged perineural activity. Only intrathecal gadolinium MR myelography clearly identified a slow leak from a perineural cyst. In eight remaining cases, the leak site was unknown; however, two of these showed indirect signs of CSF leak on RC. CSF slow leaks from perineural cysts were the most common presumed etiology; and the cysts were best visualized on myelography. Conclusion RC is comparable to CT myelography but has spatial limitations and should be limited to atypical cases. |
4 |
65. Stephen CD, Rojas R, Lioutas VA, Papavassiliou E, Simon DK. Complicated spontaneous intracranial hypotension treated with intrathecal saline infusion. Pract. neurol.. 16(2):146-9, 2016 Apr. |
Review/Other-Dx |
1 patient |
To discuss the complicated spontaneous intracranial hypotension treated with intrathecal saline infusion. |
No results stated in the abstract. |
4 |
66. Sass C, Kosinski C, Schmidt P, Mull M, Schulz J, Schiefer J. Intrathecal saline infusion: an emergency procedure in a patient with spontaneous intracranial hypotension. Neurocrit Care. 19(1):116-8, 2013 Aug. |
Review/Other-Dx |
1 patient |
To report a dramatic case of SIH with life-threatening bilateral hygroma and uncal herniation. |
A 44-year-old male patient presenting with orthostatic headache and double vision was diagnosed with SIH. Diagnostic imaging showed meningeal enhancement and bilateral hygroma. A conservative treatment regime was initiated. The patient's condition rapidly deteriorated with progressive loss of consciousness. Cranial MRI showed beginning uncal herniation. As an emergency treatment measure, an intracranial pressure (ICP) probe was inserted and intrathecal lumbal saline infusion was initiated. This led to a stabilization of ICP and allowed further diagnostics and treatment. |
4 |
67. Binder DK, Dillon WP, Fishman RA, Schmidt MH. Intrathecal saline infusion in the treatment of obtundation associated with spontaneous intracranial hypotension: technical case report. Neurosurgery. 51(3):830-6; discussion 836-7, 2002 Sep. |
Review/Other-Dx |
1 patient |
To discuss Intrathecal saline infusion in the treatment of obtundation associated with spontaneous intracranial hypotension |
Despite treatment with lumbar epidural blood patch, worsening stupor necessitated intubation and mechanical ventilation. Contrast-enhanced magnetic resonance imaging and computed tomographic myelography of the spine failed to demonstrate the site of cerebrospinal fluid fistula. The enlarging subdural fluid collections were drained, and a ventriculostomy was performed. Postoperatively, the patient remained semicomatose. To restore intraspinal and intracranial pressures, intrathecal infusion of saline was initiated. After several hours of lumbar saline infusion, lumbar and intracranial pressures normalized, and the patient's stupor resolved rapidly. Repeat computed tomographic myelography accomplished via C1-C2 puncture demonstrated a large ventrolateral T1-T3 leak, which was treated successfully with a thoracic epidural blood patch. Follow-up magnetic resonance imaging demonstrated resolution of intracranial hypotension, and the patient was discharged in excellent condition. |
4 |
68. Farb RI, Nicholson PJ, Peng PW, et al. Spontaneous Intracranial Hypotension: A Systematic Imaging Approach for CSF Leak Localization and Management Based on MRI and Digital Subtraction Myelography. Ajnr: American Journal of Neuroradiology. 40(4):745-753, 2019 04. |
Review/Other-Dx |
31 patients |
To present a high yield systematic imaging strategy using brain and spine MRI combined with digital subtraction myelography for CSF leak localization. |
Thirty-one consecutive patients with spontaneous intracranial hypotension were included. The site of CSF leakage was definitively located in 27 (87%). Of these, 21 were positive for spinal longitudinal extradural CSF collection and categorized as having a ventral (type 1, fifteen [48%]) or lateral dural tear (type 2; four [13%]). Ten patients were negative for spinal longitudinal extradural CSF collection and were categorized as having a CSF-venous fistula (type 3, seven [23%]) or distal nerve root sleeve leak (type 4, one [3%]). The locations of leakage of 2 patients positive for spinal longitudinal extradural CSF collection remain undefined due to resolution of spontaneous intracranial hypotension before repeat digital subtraction myelography. In 2 (7%) patients negative for spinal longitudinal extradural CSF collection, the site of leakage could not be localized. Nine of 21 (43%) patients positive for spinal longitudinal extradural CSF collection were treated successfully with an epidural blood patch, and 12 required an operation. Of the 10 patients negative for spinal longitudinal extradural CSF collection (8 localized), none were effectively treated with an epidural blood patch, and all have undergone (n = 7) or are awaiting (n = 1) an operation. |
4 |
69. Kranz PG, Gray L, Malinzak MD, Houk JL, Kim DK, Amrhein TJ. CSF-Venous Fistulas: Anatomy and Diagnostic Imaging. [Review]. AJR. American Journal of Roentgenology. 217(6):1418-1429, 2021 12. |
Review/Other-Dx |
N/A |
To review 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. |
No results stated in the abstract. |
4 |
70. Amrhein TJ, Gray L, Malinzak MD, Kranz PG. Respiratory Phase Affects the Conspicuity of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension. Ajnr: American Journal of Neuroradiology. 41(9):1754-1756, 2020 09. |
Review/Other-Dx |
5 patients |
To describe how the respiratory phase affects the visibility of CSF-venous fistulas during myelography. |
The mean patient age was 60 years (range, 44–68 years), and 40% were women. All patients in this series coincidentally had undergone 2 CTMs before images were acquired with attention to the phase of the respiratory cycle. In all patients, 1 of the 2 prior CTMs had negative findings, and the other demonstrated a subtle finding suspicious for a CVF, which formed the basis for the decision to acquire the images depicted in this report. CVFs all originated from nerve root sleeves, consistent with previous reports, and were identified on the right at T9 and on the left at C8, T2, T8, and T10.8 |
4 |
71. Schievink WI, Maya MM, Jean-Pierre S, Moser FG, Nuno M, Pressman BD. Rebound high-pressure headache after treatment of spontaneous intracranial hypotension: MRV study. Neurology Clinical Practice. 9(2):93-100, 2019 Apr. |
Observational-Dx |
93 patients |
To assess for cerebral venous sinus stenosis, a risk factor for idiopathic intracranial hypertension. |
The mean age of the 46 men and 67 women was 45.9 years (range 13-71 years) at the time of onset of SIH. Rebound high-pressure headache was diagnosed in 31 patients (27.4%); 14% of patients with an MRV score of 0, 24% with a score of 1, and 46% with a score of 2 or 3 (p = 0.0092). Also, compared to SIH patients who did not develop rebound high-pressure headaches (n = 82), those with rebound high-pressure headaches were younger, more often female, and more often had an extradural CSF collection on spinal imaging. |
2 |
72. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |