1/47. Spontaneous intracranial hypotension.PURPOSE: To describe a patient with classic presentation of spontaneous intracranial hypotension and subsequent improvement with targeted epidural blood patch. methods: Report of one case and review of the literature. RESULTS: Examination of cerebrospinal fluid after lumbar puncture disclosed a reduced opening pressure, an increased level of protein, and lymphocytic pleocytosis. magnetic resonance imaging of the brain with gadolinium showed diffuse enhancement of the pachymeninges, no evidence of leptomeningeal enhancement, and chronic subdural fluid collection. Radionuclide cisternography demonstrated reduced activity over the cerebral convexities, early accumulation of radiotracer in the urinary bladder, and direct evidence of leakage at the cervicothoracic junction (C7-T1). Clinical, laboratory, and radiologic features were consistent with the diagnosis of spontaneous intracranial hypotension. Therapy with a targeted epidural blood patch resulted in the rapid resolution of symptoms. CONCLUSIONS: In this report, we describe a classic case of spontaneous intracranial hypotension in a 63-year-old man with an initial presentation of postural headaches, blurred vision, pain in the left eye, diplopia on left gaze, and neck soreness.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/47. Pseudo Chiari type I malformation secondary to cerebrospinal fluid leakage.Cerebrospinal fluid (CSF) leakage may occur spontaneously, iatrogenically or from spinal trauma. Postural headache is the cardinal symptom; dizziness, diminished hearing, nausea and vomiting are additional symptoms. In neurological examinations cranial nerve palsies may be found. Due to low CSF pressure neuroimaging studies may reveal dural enhancement and vertical displacement of the brain. We describe a patient with the history of an uncomplicated lumbar discectomy at the level L4-5 and the typical clinical symptoms of intracranial hypotension. MRI of the craniocervical junction showed typical features of a Chiari type-I malformation. After neurosurgical ligation of a CSF leak at L4-5 caused by lumbar disc surgery, the patient was free of orthostatic headache. A repeated MRI showed a striking reduction of the previous downward displacement of the cerebellar tonsils and pons.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/47. Low-pressure shunt 'malfunction' following lumbar puncture in children with shunted obstructive hydrocephalus.Most shunt malfunctions present with signs and symptoms of high intracranial pressure, and computed tomography scans demonstrate ventricular enlargement. However, several authors have described a rare 'low-pressure' hydrocephalic state in which ventricular enlargement can occur in the face of low, or even negative, intracranial pressures. We report 2 children with obstructive hydrocephalus in whom this 'low-pressure state' followed a lumbar puncture; in both children, the shunts were functioning properly despite increased ventricular size on computed tomography scans, and all symptoms resolved (and the ventricles returned to baseline) following a period of enforced recumbency without shunt revision. We hypothesize that subarachnoid cerebrospinal fluid leakage through the puncture site in the lumbar theca decreases the intracranial pressures globally to a point below the opening pressures of the shunt valves. The ventricular cerebrospinal fluid, unable to be drained through either the subarachnoid space or the shunt, accumulates within the ventricular system under low pressure. One consistent feature in our 2 patients has been the postural nature of the headaches. We recommend enforced recumbency and, if necessary, a blood patch to seal the lumbar leakage. Shunt revision or prolonged external ventricular drainage appears to be unnecessary in these patients. Finally, neurosurgeons should be aware of this potential complication.- - - - - - - - - - ranking = 11keywords = pressure (Clic here for more details about this article) |
4/47. New-onset headache in an adolescent with MASS syndrome.A 15-year-old girl with the "MASS" 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.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/47. Spontaneous intracranial hypotension: use of unenhanced MRI.We report a case of spontaneous intracranial hypotension diagnosed with unenhanced cranial MRI, showing laminar subdural fluid and engorgement of the hypophysis and perisellar sinuses. cerebrospinal fluid pressure was low. MRI was normal after resolution of symptoms. Prior reports emphasise the enhancing pachymeninges seen in this syndrome. We maintain that, when subdural collections and perisellar engorgement are detected on unenhanced MRI in the proper clinical setting, contrast enhancement may not be necessary for the diagnosis.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
6/47. Increasing chronic subdural hematoma after endoscopic III ventriculostomy.OBJECT: Endoscopic III ventriculostomy (ETV) is an effective and a rather safe treatment for noncommunicating hydrocephalus secondary to aqueductal stenosis and other obstructive pathologies. Though not devoid of risk, ETV is increasingly replacing shunt operations, and it prevents related complications, including overdrainage. methods: We report a rare case of a large chronic subdural hematoma (ChSDH) after ETV in a patient with aqueductal stenosis. Three weeks after he was shunted elsewhere, he presented to us with clinical symptoms of intracranial hypotension and overdrainage. ETV was performed and the shunt removed uneventfully. On routine postoperative MRI a few weeks later, a large ChSDH was noted, the patient being totally asymptomatic. Since the ChSDH grew significantly, causing a mass effect on the follow-up MRI, it was finally drained. Large and increasing ChSDHs have previously been reported secondary to overdrainage after shunt placement, but not after ETV. CONCLUSIONS: We conclude that though rare, a ChSDH may evolve even after ETV, if there is a substantial decrease in previously elevated intracranial pressure.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/47. Spontaneous intracranial hypotension associated with bilateral chronic subdural hematomas--case report.A 34-year-old female presented with spontaneous intracranial hypotension (SIH) manifesting as severe postural headache and meningism. Magnetic resonance (MR) imaging with gadolinium showed diffuse pachymeningeal enhancement. She developed bilateral chronic subdural hematomas 4 weeks after the onset of the symptoms. MR imaging showed descent of the midline structures of the brain. The bilateral chronic subdural hematomas were surgically drained, with no remarkable pressure. Postoperative MR imaging showed complete resolution of the pachymeningeal enhancement and relevation of the midline structures of the brain. SIH is an uncommon and probably unrecognized condition because of the usually benign course. However, this case emphasizes that SIH is not entirely benign. SIH should be considered if there is no identifiable risk for intracranial hemorrhage, particularly in young patients. Neurosurgical intervention for the treatment of the underlying cerebrospinal fluid leak may be required if SIH persists.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
8/47. Absent headache despite CSF volume depletion (intracranial hypotension).CSF volume depletions, whether from leak or shunt overdrainage, typically cause low CSF opening pressures, orthostatic headaches, and diffuse pachymeningeal gadolinium enhancement on MRI. The authors report three patients-two with overdraining CSF shunts and one with proven CSF leak-with the typical pachymeningeal enhancement but without headaches. In CSF leaks and CSF shunt overdrainage, like MRI abnormalities and CSF alterations, the clinical features also show considerable variability. The independent variable remains the CSF volume depletion.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/47. intracranial hypotension: the nonspecific nature of MRI findings.We present three patients who complained of postural headache related to different types of intracranial hypotension: spontaneous or primary, and secondary, but presenting the same findings on brain magnetic resonance imaging. Diffuse pachymeningeal gadolinium enhancement supports the belief that the enhancement is a nonspecific meningeal reaction to low pressure.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/47. Spontaneous intracranial hypotension during pregnancy.BACKGROUND: Spontaneous intracranial hypotension is characterized by postural headache associated with low cerebrospinal fluid pressure. CASE: A 37-year-old Japanese woman, gravida 3, para 2, had sudden onset of severe postural headache at 8 weeks' gestation, accompanied by nausea and vomiting. Results of medical and neurologic examinations were normal, and there was no measurable cerebrospinal fluid pressure on lumbar puncture. brain magnetic resonance imaging showed diffuse subdural fluid collection and a narrowing of the ambient cistern, confirming the diagnosis of spontaneous intracranial hypotension. After a month of bed rest and intravenous fluid infusion, all symptoms subsided gradually and did not recur. CONCLUSION: Obstetricians should be aware that spontaneous intracranial hypotension can occur in pregnancy.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
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