Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-25T08:05:22.051Z Has data issue: false hasContentIssue false
  • English
  • Français

Spontaneous Intracranial Hypotension: Recommendations for Management

Published online by Cambridge University Press:  23 September 2014

Farnaz Amoozegar ,
Darryl Guglielmin ,
William Hu ,
Denise Chan  and
Werner J. Becker
Farnaz Amoozegar
Affiliation:
Department of Clinical Neurosciences, University of Calgary Foothills Medical Centre, Calgary, Alberta, Canada
Darryl Guglielmin
Affiliation:
Department of Anesthesia, University of Calgary Foothills Medical Centre, Calgary, Alberta, Canada
William Hu
Affiliation:
Department of Diagnostic Imaging, University of Calgary Foothills Medical Centre, Calgary, Alberta, Canada
Denise Chan
Affiliation:
Department of Diagnostic Imaging, University of Calgary Foothills Medical Centre, Calgary, Alberta, Canada
Werner J. Becker
Affiliation:
Department of Clinical Neurosciences, University of Calgary Foothills Medical Centre, Calgary, Alberta, Canada
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

A literature search found no clinical trials or guidelines addressing the management of spontaneous intracranial hypotension (SIH). Based on the available literature and expert opinion, we have developed recommendations for the diagnosis and management of SIH. For typical cases, we recommend brain magnetic resonance (MR) imaging with gadolinium to confirm the diagnosis, and conservative measures for up to two weeks. If the patient remains symptomatic, up to three non-directed lumbar epidural blood patches (EBPs) should be considered. If these are unsuccessful, non-invasive MR myelography, radionuclide cisternography, MR myelography with intrathecal gadolinium, or computed tomography with myelography should be used to localize the leak. If the leak is localized, directed EPBs should be considered, followed by fibrin sealant or neurosurgery if necessary. Clinically atypical cases with normal brain MR imaging should be investigated to localize the leak. Directed EBPs can be used if the leak is localized; non-directed EBPs should be used only if there are indirect signs of SIH.

Résumé

RÉSUMÉ

Nous n'avons trouvéucun essai clinique ou ligne directrice sur le traitement de l'hypotension intracrâenne spontané(HIS) lors d'une recherche de la littéture. Nous avons éborées recommandations sur le diagnostic et le traitement de l'HIS fondé sur la littéture disponible et l'avis d'experts. Chez les cas typiques, nous recommandons de procér àne IRM cébrale avec gadolinium pour confirmer le diagnostic et de prescrire un traitement conservateur pour une péode de temps allant jusqu'àeux semaines. Si le patient demeure symptomatique, on devrait envisager de faire jusqu'àrois blood patches édurales lombaires non dirigé. Si ce traitement ne donne pas de réltat, une myégraphie non effractive par rénance magnéque, une cisternographie isotopique, une myégraphie par rénance magnéque avec gadolinium intrathél ou une myégraphie par tomodensitoméie devrait êe effectuéafin de localiser la fuite. Si la fuite est localisé on devrait envisager de faire des blood patches dirigé suivies de l'administration d'un scellant de fibrine ou avoir recours àa neurochirurgie si néssaire. Chez les cas atypiques au point de vue clinique, qui ont une IRM cébrale normale, on devraient essayer de localiser lafuite. Des blood patches dirigé peuvent êe utilisési la fuite est localisé Des blood patches non dirigé ne devraient êe utilisé que s'il y a des signes indirects d'HIS.

Type
Review Article
Information
Canadian Journal of Neurological Sciences , Volume 40 , Issue 2 , March 2013 , pp. 144 - 157
Copyright
Copyright © The Canadian Journal of Neurological 2013

References

1. Schievink, WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295(19):2286–96.CrossRefGoogle ScholarPubMed
2. Headache classification subcommittee of the international earache society. The international classification of headache disorders: 2nd Edition. Cephalalgia. 2004;24 Suppl 1:9–160.Google Scholar
3. Schievink, WI, Maya, MM, Louy, C, Moser, FG, Tourje, J. Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol. 2008 May;29(5):853–6. Epub 2008 Feb 7.Google Scholar
4. Huntoon, MA, Watson, JC. Intracranial hypotension following motor vehicle accident: an overlooked cause of post-traumatic head and neck pain? Pain Pract. 2007;7(1):47–52.Google Scholar
5. Ishikawa, S, Yokoyama, M, Moriyama, E, et al. Epidural blood patch therapy for chronic whiplash associated disorder. IARS Abstracts. Available from: http://www.abstractsonline.org/viewer/viewAbstractPrintFriendly.asp Google Scholar
6. Mokri, B. Headache associated with low CSF pressure. Medlink Neurology. Available from: www.medlink.com Google Scholar
7. Schwedt, TJ, Dodick, DW. Spontaneous intracranial hypotension. Curr Pain Headache Rep. 2007 Feb;11(1):56–61.Google Scholar
8. Balgera, R, Rigamonti, A, Sozzi, G, Agostoni, E. An atypical case of spontaneous intracranial hypotension. Neurol Sci. 2009 Feb;30(1):71–3.Google Scholar
9. Matharu, MS, Schwedt, TJ, Dodick, DW. Thunderclap headache: an approach to a neurologic emergency. Curr Neurol Neurosci Rep. 2007 Mar;7(2):101–9.Google Scholar
10. Ferrante, E, Savino, A. Thunderclap headache caused by spontaneous intracranial hypotension. Neurol Sci. 2005 May;26 Suppl 2:s155–7.Google Scholar
11. Mokri, B, Atkinson, JLD, Piepgras, DG. Absent headache despite CSF volume depletion (intracranial hypotension). Neurology. 2000 Dec 12;55(11):1722–4.Google Scholar
12. Mokri, B, Aksamit, AJ, Atkinson, JLD. Paradoxical postural headaches in cerebrospinal fluid leaks. Cephalalgia. 2004;24:883–7.Google Scholar
13. Mokri, B, Low, PA. Orthostatic headaches without CSF leak in postural tachycardia syndrome. Neurology. 2003 Oct 14;61(7):980–2.Google Scholar
14. Leep Hunderfund, AN, Mokri, B. Orthostatic headache without CSF leak. Neurology. 2008 Dec 2;71(23):1902–6.Google Scholar
15. 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. 2009 Jan;30(1):147–51. Epub 2008 Sep 3.Google Scholar
16. Haritanti, A, Karacostas, D, Drevelengas, A, et al. Spontaneous intracranial hypotension: Clinical and neuroimaging findings in six cases with literature review. Eur J Radiol. 2009 Feb;69(2):253–9.CrossRefGoogle ScholarPubMed
17. Tosaka, M, Sato, N, Fujimaki, H, et al. Diffuse pachymeningeal hyperintensity and subdural effusion/hematoma detected by fluid-attenuated inversion recovery MR imaging in patients with spontaneous intracranial hypotension. AJNR Am J Neuroradiol. 2008 Jun;29(6):1164–70. Comment: AJNR Am, J Neuroradiol. 2009 Mar;30(3): E41; author reply E42.Google Scholar
18. Chiapparini, L, Ciceri, E, Nappini, S, et al. Headache and intracranial hypotension: neuroradiological findings. Neurol Sci. 2004 Oct;25 Suppl 3:S138–41.Google Scholar
19. Ferrante, E, Savino, A, Sances, G, Nappi, G. Spontaneous intracranial hypotension syndrome: report of twelve cases. Headache. 2004 Jun;44(6):615–22.Google Scholar
20. Schoffer, KL, Benstead, TJ, Grant, I. Spontaneous intracranial hypotension in the absence of magnetic resonance imaging abnormalities. Can J Neurol Sci. 2002 Aug;29(3):253–7.Google Scholar
21. Ferrante, E, Riva, M, Gatti, A, et al. Intracranial hypotension syndrome: neuroimaging in five spontaneous cases and etiopathogenetic correlations. Clin Neurol Neurosurg. 1998 Mar;100(1):33–9.Google Scholar
22. Lin, WC, Lirng, JF, Fuh, JL, et al. MR findings of spontaneous intracranial hypotension. Acta Radiol. 2002 May;43(3):249–55.Google Scholar
23. Chen, CJ, Lee, TH, Hsu, HL, Tseng, YC, Wong, YC, Wang, LJ. Spinal MR findings in spontaneous intracranial hypotension. Neuroradiology. 2002 Dec;44(12):996–1003.Google Scholar
24. Chiapparini, L, Farina, L, D’Incerti, L, et al. Spinal radiological findings in nine patients with spontaneous intracranial hypotension. Neuroradiology. 2002 Feb;44(2):143–50; discussion 151-2.Google Scholar
25. Farb, RI, Forghani, R, Lee, SK, Mikulis, DJ, Agid, R. The venous distension sign: a diagnostic sign of intracranial hypotension at MR Imaging of the brain. AJNR Am J Neuroradiol. 2007 Sept;28:1489–93.Google Scholar
26. Shankar, JJ, Chakraborty, S, Lum, C. The venous hinge - An objective sign for the diagnosis and follow-up of treatment in patients with intracranial hypotension syndrome. Neuroradiology. 2009 Jul;51(7):453–6.Google Scholar
27. Hyun, SH, Lee, KH, Lee, SJ, et al. Potential value of radionuclide cisternography in diagnosis and management planning of spontaneous intracranial hypotension. Clin Neurol Neurosurg. 2008 Jul;110(7):657–61.Google Scholar
28. Morioka, T, Aoki, T, Tomoda, Y, et al. Cerebrospinal fluid leakage in intracranial hypotension syndrome: usefulness of indirect findings in radionuclide cisternography for detection and treatment monitoring. Clin Nucl Med. 2008 Mar;33(3):181–5.Google Scholar
29. Thomas, DL, Menda, Y, Graham, MM. Radionuclide cisternography in detecting cerebrospinal fluid leak in spontaneous intracranial hypotension: a series of four case reports. Clin Nucl Med. 2009 Jul;34(7):410–16.Google Scholar
30. Yoo, HM, Kim, SJ, Choi, CG, et al. Detection of CSF leak in spinal CSF leak syndrome using MR myelography: correlation with radioisotope cisternography. AJNR. 2008 Apr;29(4):649–54.Google Scholar
31. Moriyama, E, Ogawa, T, Nishida, A, Ishikawa, S, Beck, H. Quantitative analysis of radioisotope cisternography in the diagnosis of intracranial hypotension. J Neurosurg. 2004 Sep;101(3):421–6.Google Scholar
32. Novotny, C, Pötzi, C, Asenbaum, S, Peloschek, P, Suess, E, Hoffmann, M. SPECT/CT fusion imaging in radionuclide cisternography for localization of liquor leakage sites. J Neuroimaging. 2009 Jul;19(3):227–34.Google Scholar
33. Sakurai, K, Nishio, M, Sasaki, S, et al. Post puncture CSF leakage: a potential pitfall of radionuclide cisternography. Neurology. 2010 Nov 9;75(19):1730–4.Google Scholar
34. Albayram, S, Kilic, F, Ozer, H, Baghaki, S, Kocer, N, Isak, C. Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. AJNR Am J Neuroradiol. 2008 Jan;29(1):116–21.Google Scholar
35. Dillon, WP. Intrathecal gadolinium: its time has come. AJNR Am J Neuroradiol. 2008 Jan;29:1–4.Google Scholar
36. Luetmer, PH, Mokri, B. Dynamic CT myelography: a technique for localizing high-flow spinal cerebrospinal fluid leaks. AJNR Am J Neuroradiol. 2003 Sep;24(8):1711–14.Google Scholar
37. Fujimaki, H, Saito, N, Tosaka, M, Tanaka, Y, Horiguchi, K, Sasaki, T. Cerebrospinal fluid leak demonstrated by three-dimensional computed tomographic myelography in patients with spontaneous intracranial hypotension. Surg Neurol. 2002 Sep-Oct;58(3-4):280–4; discussion 284-5.Google Scholar
38. Vanopdenbosch, LJ, Dedeken, P, Casselman, JW, Vlaminck, S. MRI with intrathecal gadolinium to detect a CSF leak: a prospective open-label cohort study. J Neurol Neurosurg Psychiatry. 2011;82:456–8.CrossRefGoogle Scholar
39. Tomoda, Y, Korogi, Y, Aoki, T, et al. Detection of cerebrospinal fluid leakage: Initial experience with three-dimensional fast spin-echo magnetic resonance myelography. Acta Radiol. 2008 Mar;49(2):197–203.Google Scholar
40. Wang, YF, Lirng, JF, Fuh, JL, Hseu, SS, Wang, SJ. Heavily T2-weighted MR myelography vs. CT myelography in spontaneous intracranial hypotension. Neurology. 2009 Dec 1;73(22):1892–8.Google Scholar
41. Hoxworth, JM, Patel, AC, Bosch, EP, Nelson, KD. Localization of a rapid CSF leak with digital subtraction myelography. AJNR Am J Neuroradiol. 2009 Mar;30(3):516–19.Google Scholar
42. Leep Hunderfund, AN, Mokri, B. Orthostatic headache without CSF leak. Neurology. 2008 Dec 2;71(23):1902–6.Google Scholar
43. Turnbull, DK, Shepherd, DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91(5):718–29.Google Scholar
44. Ohwaki, K, Yano, E, Ishii, T, Takanashi, S, Nakagomi, T. Symptom predictors of cerebrospinal fluid leaks. Can J Neurol Sci. 2008 Sep;35(4):452–7.Google Scholar
45. Hannerz, J, Dahlgren, G, Irestedt, L, Meyerson, B, Ericson, K. Treatment of idiopathic intracranial hypotension: cervicothoracic and lumbar blood patch and peroral steroid treatment. Headache. 2006 Mar;46(3):508–11.Google Scholar
46. Gentile, S, Giudice, RL, Martino, PD, Rainero, I, Pinessi, L. Headache attributed to spontaneous low CSF pressure: report of three cases responsive to corticosteroids. Eur J Neurol. 2004 Dec;11(12):849–51.Google Scholar
47. Pascual, LF, Santos, S, Escalza, I, Iñiguez, C, Morales-Asín, F. Spontaneous intracranial hypotension: quick clinical and magnetic resonance imaging response to corticosteroids, a case report. Headache. 2002 May;42(5):359–61.Google Scholar
48. Fichtner, J, Fung, C, Z’Graggen, W, et al. Lack of increase in intracranial pressure after epidural blood patch in spinal cerebrospinal fluid leak. Neurocrit Care. 2012 Jun;16(3):444–9.Google Scholar
49. Kroin, SJ, Nagalla, SKS, Buvanendran, A, McCarthy, RJ, Tuman, KJ, Ivankovich, AD. The mechanisms of intracranial pressure modulation by epidural blood and other injectates in a postdural puncture rat model. Anesth Analg. 2002;95:423–9.Google Scholar
50. Boezaart, AP. Effects of cerebral spinal fluid loss and epidural blood patch on cerebral blood flow in swine. Reg Anesth Pain Med. 2001;26:401–6 Google Scholar
51. Diaz, JH, Weed, JT. Correlation of adverse neurological outcomes with increasing volumes and delayed administration of autologous epidural blood patches for postdural puncture headaches. Pain Pract. 2005 Sep;5(3):216–22.Google Scholar
52. Warwick, WI, Neal, JM. Beyond spinal headache: prophylaxis and treatment of low-pressure headache syndromes. Reg Anesth Pain Med. 2007;32:455–61.Google Scholar
53. Malone, RE, Love, JN. Spontaneous intracranial hypotension: case report and relevant review of the literature. J Emerg Med. 2007;4:371–4.Google Scholar
54. Ferrante, E, Arpino, I, Citterio, A. Is it a rational choice to treat with lumbar epidural blood patch headache caused by spontaneous cervical CSF leak? Cephalalgia. 2006;26:1245–6.Google Scholar
55. Hannerz, J, Dalgren, G, Irestedt, L, Meyerson, B, Ericson, K. Treatment of idiopathic intracranial hypotension: cervicothoracic and lumber patch and peroral steroid treatment. Headache. 2006;46:508–11.Google Scholar
56. Beards, SC, Jackson, A, Griffiths, AG, Horsman, EL. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 hr. Br J Anaesth. 1993;71:182–8.Google Scholar
57. Schievink, WI. Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia. 2008;28:1347–56.Google Scholar
58. Cook, MA, Watkins-Pitchford, JM. Epidural blood patch: a rapid coagulation response. Anesth Analg. 1990;70(5):567–8.Google Scholar
59. Mangam, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR. The hospital infection control practices advisory committee. Guideline for prevention of surgical site infection, 1999. Infec Control Hosp Epidemiol. 1999;20(4):47–78.Google Scholar
60. Ferrante, E. Epidural blood patch in Trendelenburg position pre-medicated with acetazolamide to treat spontaneous intracranial hypotension. Eur J Neurol. 2010;17:715–19.Google Scholar
61. Ferrante, E. Coma resulting from spontaneous intracranial hypotension treated with the epidural blood patch in the Trendelenburg position pre-medicated with acetazolamide. Clin Neurol Neurosurg. 2009;111:699–702.Google Scholar
62. Mokri, B. Intracranial hypertension after treatment of spontaneous cerebrospinal fluid leaks. Mayo Clin Proc. 2002 Nov;77(11):1241–6.Google Scholar
63. Cestari, DM, Rizzo, JF. III Intracranial hypertension following epidural blood patch. Neurology. 2003 Nov (1 of 2);61:1303.Google Scholar
64. Sperry, RJ, Gartrell, A, Johnson, JO. Epidural blood patch can cause acute neurologic deterioration. Anesthesiology. 1995;82:303–5.Google Scholar
65. Philipps, J, Busse, O. From low to high: Late-onset intracranial hypertension after treatment of spontaneous intracranial hypotension. J Neurol. 2007 Jul;254(7):956–7.Google Scholar
66. Schievink, WI, Maya, MM, Moser, FM. Treatment of spontaneous intracranial hypotension with percutaneous placement of a fibrin sealant. J Neurosurg. 2004;100:1098–100.Google Scholar
67. Walega, D, McComb, E, Rosenow, J. Bilateral cervicothoracic transforaminal blood patches for persistent headache from spontaneous intracranial hypotension. Clin J Pain. 2011;27:357–64.Google Scholar
68. Banks, S, Paech, M, Gurrin, L. An audit of epidural blood patch after accidental dural puncture with a Tuohy needle in obstetric patients. Int J Obstet Anesth. 2001;10:172–6.Google Scholar
69. Tsui, H, Wu, S, Kuo, H, Chen, C. Rebound intracranial hypertension after treatment of spontaneous intracranial hypotension. Eur J Neurol. 2006;13:780–2.Google Scholar
70. Gill, JB, Heavner, JE. Visual impairment following epidural fluid injections and epiduroscopy: a review. Pain Med. 2005;6:367–74.Google Scholar
71. Sencakova, D, Mokri, B, McClelland, RL. The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology. 2001 Nov 27;57(10):1921–3.Google Scholar
72. Ferrante, E, Rubino, GF, Passarani, S, Arpino, I. Spontaneous intracranial hypotension. J Neurosurg. 2010 Aug;113(2):397–8.Google Scholar
73. Berroir, S, Loisel, B, Ducros, A, et al. Early epidural blood patch in spontaneous intracranial hypotension. Neurology. 2004 Nov 23;63(10):1950–1.Google Scholar
74. Su, CS, Lan, MY, Chang, YY, Lin, WC, Liu, KT. Clinical features, neuroimaging and treatment of spontaneous intracranial hypotension and magnetic resonance imaging evidence of blind epidural blood patch. Eur Neurol. 2009;61(5):301–7.Google Scholar
75. Rozec, B, Guillon, B, Desal, H, Blanloeil, Y. Value of epidural blood-patches for the treatment of spontaneous intracranial hypotension. Ann Fr Anesth Reanim. 2004 Dec;23(12):1144–8.Google Scholar
76. Horikoshi, T, Watanabe, A, Uchida, M, Kinouchi, H. Effectiveness of an epidural blood patch for patients with intracranial hypotension syndrome and persistent spinal epidural fluid collection after treatment. J Neurosurg. 2010 Nov;113(5):940–6.Google Scholar
77. Mehta, B, Tarshis, J. Repeated large-volume epidural blood patches for the treatment of spontaneous intracranial hypotension. Can J Anaesth. 2009 Aug;56(8):609–13.Google Scholar
78. Franzini, A, Messina, G, Nazzi, V, et al. Spontaneous intracranial hypotension syndrome: a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients. J Neurosurg. 2010 Feb;112(2):300–6.Google Scholar
79. Groen, RJ, Hoogland, PV. Spontaneous intracranial hypotension. J Neurosurg. 2010 Sep;113(3):685–8.CrossRefGoogle ScholarPubMed
80. Inamasu, J, Nakatsukasa, M. Blood patch for spontaneous intracranial hypotension caused by cerebrospinal fluid leak at C1-2. Clin Neurol Neurosurg. 2007 Oct;109(8):716–19.Google Scholar
81. Cousins, MJ, Brazier, D, Cook, R. Intracranial hypotension caused by cervical cerebrospinal fluid leak: treatment with epidural blood patch. Anesth Analg. 2004 Jun;98(6):1794–7.Google Scholar
82. Rai, A, Rosen, C, Carpenter, J, Miele, V. Epidural blood patch at C2: diagnosis and treatment of spontaneous intracranial hypotension. AJNR. 2005 Nov-Dec;26(10):2663–6.Google Scholar
83. Cho, Ki, Moon, HS, Jeon, HJ, Park, K, Kong, DS. Spontaneous intracranial hypotension: efficacy of radiologic targeting vs. blind blood patch. Neurology. 2011;76:1139–44.Google Scholar
84. Gladstone, JP, Nelson, K, Patel, N, Dodick, DW. Spontaneous CSF leak treated with percutaneous CT-guided fibrin glue. Neurology. 2005 May 24;64(10):1818–19.Google Scholar
85. Garcia-Aguado, R, Gil, F, Barcia, JA, et al. Prophylactic percutaneous sealing of lumbar postdural puncture hole with fibrin glue to prevent cerebrospinal fluid leakage in swine. Anesth Analog. 2000;90:894–8.Google Scholar
86. Mokri, B. Expert commentary: role of surgery for the management of CSF leaks. Cephalalgia. 2008;28:1357–60.Google Scholar
87. Cohen-Gadol, AA, Mokri, B, Piepgras, DG, Meyer, FB, Atkinson, JL. Surgical anatomy of dural defects in spontaneous spinal cerebrospinal fluid leaks. J Neurosurg. 2006 Apr;58(4 Suppl 2): ONS-238-45; discussion ONS-245.Google Scholar
88. Schievink, WI. A novel technique for treatment of intractable spontaneous intracranial hypotension: lumbar dural reduction surgery. Headache. 2009 Jul;49(7):1047–51.Google Scholar