RESUMEN
BACKGROUND AND OBJECTIVES: Existing tools to diagnose spontaneous intracranial hypotension (SIH), namely spinal opening pressure (OP) and brain MRI, have limited sensitivity. We investigated whether evaluation of brain MRI using the Bern score, combined with calculated craniospinal elastance, would aid in diagnosing SIH and provide insight into its pathophysiology. METHODS: A retrospective chart review was performed of patients who underwent brain MRI and pressure-augmented dynamic CT myelography (dCTM) for suspicion of SIH. Two blinded neuroradiologists assigned Bern scores for each brain MRI. OP and incremental pressure changes after intrathecal saline infusion were recorded to calculate craniospinal elastance. The relationship between Bern score, OP, and elastance and whether a leak was found were analyzed. RESULTS: 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. DISCUSSION: OP is not an effective predictor for diagnosing CSF leak and if used in isolation would result in misdiagnosis of 94% of patients in our cohort. The Bern score was associated with a higher diagnostic yield of dCTM. Elastance was significantly associated with certain components of the Bern score.
Asunto(s)
Hipotensión Intracraneal , Humanos , Hipotensión Intracraneal/diagnóstico por imagen , Hipotensión Intracraneal/complicaciones , Estudios Retrospectivos , Columna Vertebral , Mielografía , Imagen por Resonancia Magnética , Pérdida de Líquido Cefalorraquídeo/diagnósticoAsunto(s)
Hematoma Subdural Crónico , Hematoma Intracraneal Subdural , Hipotensión Intracraneal , Humanos , Hematoma Subdural Crónico/complicaciones , Hematoma Subdural Crónico/diagnóstico por imagen , Hipotensión Intracraneal/complicaciones , Hipotensión Intracraneal/diagnóstico por imagen , CefaleaRESUMEN
OBJECTIVE: To compare specific fetal cranial and cerebral findings indicative of prenatal intracranial hypotension (PICH) syndrome between open and closed cephaloceles. METHODS: Two groups of fetuses with cephalocele who underwent magnetic resonance imaging scan were selected based on the defect coverage: covered ("closed cephalocele" group, n = 4) and uncovered by skin ("open cephalocele" group, n = 8). The presence of signs associated with PICH syndrome was evaluated and findings compared between groups. RESULTS: Cases from the open cephalocele group showed statistically significant differences in comparison with the closed cephalocele group regarding reduction of the interpeduncular angle (p = 0.006), reduced amount of cerebrospinal fluid in the subarachnoid space (p = 0.01), collapsed/severely reduced fourth ventricle (p = 0.03), cephalocele content (p = 0.03), and identification of a vector traction (p = 0.03). There were no differences in the presence of cerebellar tonsillar descent, obstructive ventriculomegaly, and presence of the lemon sign. In comparison with gestational age-matched controls, only the biparietal diameter but not the head circumference was significantly smaller in both the open and closed cephalocele groups (p < 0.05). CONCLUSION: Congenital cephaloceles present distinct imaging behavior depending on the defect coverage. Therefore, the classification of cephalocele should include, in addition to location and content, the presence or absence of skin fully covering the defect.
Asunto(s)
Hidrocefalia , Hipotensión Intracraneal , Embarazo , Femenino , Humanos , Encefalocele/diagnóstico por imagen , Hipotensión Intracraneal/complicaciones , Hipotensión Intracraneal/diagnóstico por imagen , Diagnóstico Prenatal , Hidrocefalia/complicaciones , SíndromeRESUMEN
OBJECTIVE: To study the prevalence of abnormalities of the septi pellucidi (SP) in a cohort of fetuses with open spinal dysraphism (OSD) and to determine whether this condition is secondary to obstructive ventriculomegaly and, therefore, part of the natural history of prenatal intracranial hypotension (PICH) syndrome. METHODS: Magnetic resonance imaging (MRI) studies from fetuses with OSD were analyzed. The SP were assessed using axial and coronal T2-weighted images of the fetal brain and classified as intact, partially absent, or completely absent. Additionally, the correlation between the presence or absence of the SP and the size of the lateral ventricles, degree of cerebellar tonsillar herniation, collapse of the fourth ventricle, and interpeduncular angle was investigated. RESULTS: A total of 32 fetuses with OSD were studied. Mean gestational age at the time of the fetal MRI was 25.5 ± 3.9 weeks (range, 19-35) and mean ventricular size was 16.2 ± 4.2 mm (range, 8-26). Twenty-three (71.9%) fetuses had cerebellar tonsillar herniation. The IPA was completely collapsed in 23 cases (71.9%), reduced in seven (21.9%), and unreadable in two (6.3%). Twenty (62.5%) fetuses presented with intact SP, 10 (31.3%) with partially absent SP (incomplete fenestration), and two (6.3%) with completely absent SP (complete fenestration). Fenestration of the SP correlated significantly with the degree of ventriculomegaly (Pearson's correlation coefficient =0.459; p = .01). However, there was no correlation with the IPA, collapse of the fourth ventricle, and cerebellar tonsillar herniation. CONCLUSIONS: More than one-third of the fetuses with OSD had fenestration of the SP. The most probable etiology is increased intraventricular pressure leading to local necrosis of the SP. As fenestration of the SP is a secondary event associated with PICH syndrome, this condition should not be considered a contraindication for intrauterine repair of the spinal defect. Instead, it should be seen as an indicator of the severity of the intraventricular pressure.
Asunto(s)
Hidrocefalia , Hipotensión Intracraneal , Malformaciones del Sistema Nervioso , Disrafia Espinal , Embarazo , Femenino , Humanos , Hipotensión Intracraneal/complicaciones , Encefalocele/diagnóstico por imagen , Encefalocele/epidemiología , Encefalocele/complicaciones , Hidrocefalia/diagnóstico por imagen , Disrafia Espinal/complicaciones , Feto/diagnóstico por imagen , Malformaciones del Sistema Nervioso/complicaciones , Edad Gestacional , Imagen por Resonancia Magnética/métodos , Estudios Retrospectivos , Ultrasonografía Prenatal/métodosRESUMEN
Spontaneous intracranial hypotension (SIH) is a syndrome that was unknown until the advent of magnetic resonance imaging (MRI). It is a cause of orthostatic headache, which remains underdiagnosed and, rarely, can result in several complications including dural venous sinus thrombosis, subdural hematoma and subarachnoid hemorrhage. Some of these complications are potentially life-threatening and should be recognized promptly, mainly by imaging studies. We reviewed the MRI of nine patients with SIH and describe the complications observed in three of these patients. Two of them had subdural hematoma and one had a dural venous sinus thrombosis detected by computed tomography and MRI. We concluded that MRI findings are of great importance in the diagnosis of SIH and its complications, which often influence the clinical-surgical treatment of the patient.
Asunto(s)
Hipotensión Intracraneal/complicaciones , Hipotensión Intracraneal/diagnóstico por imagen , Adulto , Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagen , Pérdida de Líquido Cefalorraquídeo/etiología , Angiografía por Tomografía Computarizada/métodos , Femenino , Cefalea/etiología , Hematoma Intracraneal Subdural/diagnóstico por imagen , Hematoma Intracraneal Subdural/etiología , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Trombosis de los Senos Intracraneales/diagnóstico por imagen , Trombosis de los Senos Intracraneales/etiologíaRESUMEN
ABSTRACT Spontaneous intracranial hypotension (SIH) is a syndrome that was unknown until the advent of magnetic resonance imaging (MRI). It is a cause of orthostatic headache, which remains underdiagnosed and, rarely, can result in several complications including dural venous sinus thrombosis, subdural hematoma and subarachnoid hemorrhage. Some of these complications are potentially life-threatening and should be recognized promptly, mainly by imaging studies. We reviewed the MRI of nine patients with SIH and describe the complications observed in three of these patients. Two of them had subdural hematoma and one had a dural venous sinus thrombosis detected by computed tomography and MRI. We concluded that MRI findings are of great importance in the diagnosis of SIH and its complications, which often influence the clinical-surgical treatment of the patient.
RESUMO Hipotensão Intracraniana Espontânea (HIE) é uma síndrome desconhecida até o advento das imagens de Ressonância Magnética (RM). É uma causa de cefaleia ortostática que permanece subdiagnosticada e raramente resulta em complicações, como trombose de seios venosos durais, hematoma subdural e hemorragia subaracnoidea. Algumas dessas complicações são potencialmente ameaçadoras à vida e devem ser prontamente reconhecidas pelos estudos de imagem. Nós revisamos as RM de 9 pacientes com HIE e descrevemos as complicações observadas em 3 casos. Dois deles tiveram hematoma subdural e um teve trombose de seio venoso dural detectados por tomografia computadorizada e RM. Concluímos que achados de RM são de grande importância no diagnóstico de HIE e suas complicações, frequentemente influenciando o tratamento clínico-cirúrgico do paciente.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Hipotensión Intracraneal/complicaciones , Hipotensión Intracraneal/diagnóstico por imagen , Trombosis de los Senos Intracraneales/etiología , Trombosis de los Senos Intracraneales/diagnóstico por imagen , Hematoma Intracraneal Subdural/etiología , Hematoma Intracraneal Subdural/diagnóstico por imagen , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagen , Angiografía por Tomografía Computarizada/métodos , Cefalea/etiologíaRESUMEN
Intracraneal hypotension headache is a well known syndrome in neurosurgery practice. In most cases cerebrospinal fluid leaks are caused by medical interventions, such as lumbar puncture, peridural anesthesia and surgical interventions on the spine. Clinical symptoms tipically show orthostatic headache that resolves in supine position, and other symptoms like neck tightness, vertigo and diplopia. RMI diagnostic confirms paquimeningeal enhancement and subdural hygromas. Conservative treatment usually includes bed resting, hydratation and administration of caffeine or glucocorticoids, resolving spontaneously in one to four months. The importance of the diagnosis lies in the differential diagnosis with other causes of headache, as symptomatic limiting factor in the rehabilitation of the patient and the same favorable prognosis.
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Cefalea/etiología , Hipotensión Intracraneal/complicaciones , Vértebras Lumbares/cirugía , Dolor Postoperatorio/etiología , Estenosis Espinal/cirugía , Cefalea/líquido cefalorraquídeo , Cefalea/terapia , Humanos , Hipotensión Intracraneal/líquido cefalorraquídeo , Hipotensión Intracraneal/terapia , Imagen por Resonancia Magnética , Meningocele/diagnóstico por imagen , Meningocele/etiología , Persona de Mediana Edad , Dolor Postoperatorio/líquido cefalorraquídeo , Dolor Postoperatorio/terapia , Resultado del TratamientoRESUMEN
Hemorrhage in regions remote from the site of initial intracranial operations is rare, but may be fatal. Postoperative cerebellar hemorrhage as a complication of supratentorial surgery, with a radiological appearance known as zebra sign, is an increasingly recognized clinical entity and is associated mainly with vascular neurosurgery or temporal lobe resection. The pathophysiology remains unclear. Three cases of remote cerebellar hematoma occurred after neck clipping of anterior communicating artery aneurysms. All patients had similar clinical findings and underwent pterional craniotomy with the head in accentuated extension. One patient died and the two were discharged without symptoms. Cerebellar hemorrhage probably has a multifactorial origin involving positioning associated with abundant cerebrospinal fluid drainage causing cerebellar sag with resultant vein stretching and bleeding, and use of aspirin or other antiplatelet agents.
Asunto(s)
Cerebelo/fisiopatología , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/fisiopatología , Procedimientos Neuroquirúrgicos/efectos adversos , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/fisiopatología , Anciano , Enfermedades Cerebelosas/etiología , Enfermedades Cerebelosas/fisiopatología , Cerebelo/irrigación sanguínea , Cerebelo/patología , Angiografía Cerebral , Venas Cerebrales/diagnóstico por imagen , Venas Cerebrales/patología , Venas Cerebrales/fisiopatología , Craneotomía/efectos adversos , Resultado Fatal , Femenino , Humanos , Hipotensión Ortostática/complicaciones , Hipotensión Ortostática/fisiopatología , Enfermedad Iatrogénica , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/patología , Aneurisma Intracraneal/cirugía , Hemorragia Intracraneal Hipertensiva/diagnóstico por imagen , Hemorragia Intracraneal Hipertensiva/etiología , Hemorragia Intracraneal Hipertensiva/fisiopatología , Hemorragias Intracraneales/diagnóstico por imagen , Hipotensión Intracraneal/complicaciones , Hipotensión Intracraneal/fisiopatología , Cuidados Intraoperatorios/efectos adversos , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/efectos adversos , Tomografía Computarizada por Rayos X , Procedimientos Quirúrgicos Vasculares/efectos adversos , Ventriculostomía/efectos adversosRESUMEN
A hipertensão intracraniana (HIC) é um problema em pelo menos metade das lesões parenquimatosas e em um terço dos pacientes com lesão difusa. Metade dos pacientes que desenvolvem HIC morrem, a despeito da descompressão cirúrgica ou outras terapias. A clínica clássica de aumento da pressão intracraniana em adultos e em crianças consiste em cefaléia, náuseas e vômitos, além de vertigem, paralisias oculares, papiledema, turvação visual e amaurose fugaz. A mensuração da pressão intracraniana e o seu manejo adequado podem auxiliar o intensivista na otimização ds terapêuticas disponíveis atualmente para melhorar o prognóstico e a qualidade de vida dos pacientes severamente acometidos por essa condição.