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Type:
Educational Exhibit
Keywords:
Cerebrospinal fluid, Diagnostic procedure, MR, CT, Neuroradiology spine, Neuroradiology brain, CNS
Authors:
E. Ruberto1, E. Gangemi2, A. Botto1, A. M. Costantini2, M. Sciandra2, R. russo1, S. Gaudino1, C. Colosimo1; 1Rome/IT, 2Roma/IT
DOI:
10.1594/ecr2016/C-0596
Background
Intracranial hypotension is a condition of subnormal pressure levels within the brain cavity due to CSF volume depletion and resultant low CSF hydrostatic pressure.
The ultimate cause is always a “duropathy”,
a dural disorder,
either in the form of en evident breach or as a subtle dural weakness without an exact leakage site.
It can occur spontaneously or secondary to lumbar puncture,
surgery or traumatic events (Fig 1,
2).
Orthostatic headache is the most common clinical symptom that should ring a bell.
When the clinical presentation is suggestive of IH,
it should be confirmed by a MRI study of the brain.
If brain MRI imaging fulfils the criteria for IH,
the next step in the diagnostic algorithm is to investigate the cause of CSF leak.
Detection of the leakage site can be challenging and methods include spinal MRI,
MR and CT-myelogram and radioisotope cisternography.
Identification of the leak is critical to choose the right therapy.
Epidural blood patch is considered to be the safest and most efficacious option when conservative treatment does not succeed; the injection of autologous blood into the epidural space acts like a ‘stopper’ producing an arachnoid reaction that closes the leakage and,
even when no leakage point is found,
the suspicion of the presence of more than one leak supports the use of blood patch to try to close all the sites with dural defects (1).
Unlike blood patch,
a new therapy that implies epidural injection of fibrin glue requires detection of the exact site of the leakage and we still not have enough data about its outcome.
Finally,
if there is detectable leak or a meningeal diverticula,
surgical repair is the last chance for patients who have undergone more than one BP without relief (Fig 3).