Complications of Spontaneous Intracranial Hypotension

Transcription

1 Complications of Spontaneous Intracranial Hypotension Poster No.: C-0890 Congress: ECR 2015 Type: Authors: Keywords: DOI: Scientific Exhibit K. Endo, Y. Kubo, M. Ida; Tokyo/JP Hemorrhage, Embolism / Thrombosis, Acute, Diagnostic procedure, MR, Neuroradiology brain /ecr2015/C-0890 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Aims and objectives Spontaneous intracranial hypotension (SIH) is a condition developed due to negative pressure within the cranial cavity. The characteristic symptom is orthostatic headache that generally gets relieved by lying flat. SIH has been known to be associated with several complications including subdural hematoma (SDH), cerebral venous thrombosis (CVT), and subarachnoid hemorrhage (SAH). The purpose of this study is to evaluate the ratio of the complications with SIH in Tokyo Metropolitan Ebara hospital. Methods and materials Patients diagnosed with SIH from January 2007 through April 2014 were enrolled for this study. The study population consisted of 33 consecutive patients with SIH including 23 women and 10 men aged between years (with a mean age of 50 years±). Diagnostic criteria includes orthostatic headache with diffuse thickening with Gd-enhancement of the dura (fig.1) and abnormal low intracranial pressure confirmed by CSF tap. MR examination consisted of T1 and T2-weighted images (T1WI and T2WI), diffusion-weighted images (DWI), and contrast-enhanced T1WI (CE-TIWI). MR examination was performed at 1.5T or 3T. Images for this section: Page 2 of 10

3 Fig. 1: Typical MR findings of SIH (a)gd-enhanced T1WI demonstrates diffuse thickening of dura (b)flair demonstrates small subdural fluid collections. Page 3 of 10

4 Results We found 10 patients (of 33, 30.0%) with large SDH including 3 women and 7 men aged between years (with a mean age of 51 years±). In the patients, none of the patients responded with conservative treatment, and burr hole drainage was performed after the second CT or MRI (an average of 30 days (from 6 to 73 days) from the onset of symptoms) revealed an increase in SDH. We found 2 patients (of 33, 6%) with CVT including 0 women and 2 men aged between years (with a mean age of 39 years±). In one of the two patients, CVT was only revealed in the second MRI (an average of 13 days (from 12days, 14days) from the onset of symptoms. None of the patients suffered from SAH (Table 1) Representative Case of SDH with SIH: A 48-year-old man was admitted with orthostatic headache and associated neck stiffness. The opening pressure at lumber puncture was 8cm/H2O. MRI was performed 73 days after the onset of symptoms and showed bilateral large SDH (fig2a, b). Although conservative treatment such as strict bed rest and hydration therapy was continued, eight days later his condition deteriorated rapidly following admission and urgent drainage of the SDH was undertaken through bilateral burr holes. The patient made a recovery without a problem and remained well. Representative Case of CVT with SIH: A 40-year-old man was admitted with orthostatic headache. The first MRI was performed 14 days after the onset of symptoms and revealed SIH without findings of CVT (fig.3a, 4a). The occurrence of more severe headache 28 days later led to the second MRI, which revealed CVT (fig.3b, 4b). The patient was treated for CVT with heparinization, but it was resistant for CVT with SIH (fig3c, 4c). Epidural blood patch resolved clot completely (fig3d, 4d), and the patient had no further headache. Discussion 1. SDH with SIH SDH with SIH was founded in 30% cases, and the intervals of SDH occurrence spanned from 6 to 73 days, indicating the high variability. The cause is explained loss of CSF results in the formation of compensatory subdural fluid collection, which might gradually enlarge the subdural space resulting in tearing of bridging veins. The treatment doesn't have any general consensus, but evacuation of hematoma performed in all our cases improve severe headache 2. CVT with SIH Page 4 of 10

5 CVT with SIH was founded in 6% cases. It's a rare complication (28 case reports, about 2% of SIH literally). The cause is unknown, but it's explained a decrease in CSF volume must be accompanied by an increase in venous volume given. Subsequent dilatation of the intracranial veins results in slow blood flow, predisposing to clot formation. Heparinization was resistant for CVT with SIH, but epidural blood patch resolved clot in our study. Images for this section: Fig. 1: Typical MR findings of SIH (a)gd-enhanced T1WI demonstrates diffuse thickening of dura (b)flair demonstrates small subdural fluid collections. Page 5 of 10

6 Table 1: Complications of SIH Page 6 of 10

7 Fig. 2: Large SDH with SIH (a, b)flair, (c, d)ct CT shows chronic bilateral subdural hematoma worsening after conservative treatment such as strict bed rest and hydration therapy. Page 7 of 10

8 Fig. 3: CVT with SIH Gd-enhanced T1WI shows thrombus formation and worsening in the right transverse sinus in spite of conservative treatment and heparinization (b, c). Blood patch resolved the thrombus (d). Page 8 of 10

9 Fig. 4: CVT with SIH in the same case of Fig 3 Gd-enhanced T1WI shows thrombi formation in superior sagittal sinus (b, c). Blood patch resolved the thrombus (d). Page 9 of 10

10 Conclusion Our study proved most patients with SIH run a benign course, but SIH can cause life threatening complications; large SDH was found in 30%, and CVT in 6% cases. Normal compensatory mechanisms could lead to complications in SIH. Since the patient continued to have headaches, the complications need to be confirmed by MR findings. Personal information References 1. K-W. YOON, M-K. CHO, Y.J. KIM, C.S. CHO S-KL. Sinus Thrombosis in a Patient with Intracranial Hypotension#: a Suggested Hypothesis of Venous Stasis A Case Report. 2011; Lai TH, Fuh JL, Lirng JF, Tsai PH, Wang SJ. Subdural haematoma in patients with spontaneous intracranial hypotension. Cephalalgia. 2007; 27(2): Chotai S, Kim J-H, Kim J-H, Kwon T-H. Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension. Asian J Neurosurg. 2013;8(2): Noronha RJ De, Sharrack B, Hadjivassiliou M, Romanowski CAJ. Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension. 2003; Rice CM, Renowden S a, Sandeman DR, Cottrell D a. Spontaneous intracranial hypotension and venous sinus thrombosis. Pract Neurol. 2013; 13(2): Schievink WI, Maya MM, Moser FG, Tourje J. Spectrum of subdural fluid collections in spontaneous intracranial hypotension. J Neurosurg. 2005;103(4): Page 10 of 10