Advertisement

Acta Neurochirurgica

, Volume 158, Issue 2, pp 273–278 | Cite as

Treatment strategy for cerebral hypotension caused by spontaneous cerebrospinal fluid leaks

  • Insa JanssenEmail author
  • Jens Gempt
  • Julia Gerhardt
  • Bernhard Meyer
  • Yu-Mi Ryang
Clinical Article - Spine

Abstract

Objective

Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare (5 per 100,000 per year). Treatment generally consists of conservative therapy or interventional therapy with epidural blood patching. Surgical treatment is conducted rarely, usually in cases when conservative or interventional treatment has failed. The aim of our case series was to assess the clinical outcome after surgery.

Methods

Our clinical database was reviewed for patients with spontaneous spinal CSF leaks who underwent surgical exploration between 2010 and 2013. Etiology, symptoms, preoperative imaging, type of required surgical method, intraoperative findings, and clinical outcome were reported.

Results

We identified five patients with a mean age of 62 years with spontaneous spinal CSF leaks who were treated surgically. Two patients received surgery after failure of interventional treatment. The origin of the CSF leak could be identified intraoperatively in three cases. Surgical technique in all cases consisted of an interlaminar fenestration or hemilaminectomy and a complete foraminotomy to explore the thecal sack and the exiting nerve roots and identify the CSF leak. After surgery, the preoperative symptoms improved in all patients. In one case, there was a relapse after 4 weeks.

Conclusions

Preoperative identification of a CSF leak with MRI was positive in only one case. In all other cases, a post-myelography CT had to be performed. In all cases, the preoperative symptoms improved after surgery. Surgical treatment is an effective treatment of spontaneous cerebrospinal fluid leaks in cases of refractory symptoms after failed conservative or interventional treatment.

Keywords

Intracranial hypotension CSF leak Epidural blood patching Orthostatic headache Spinal meningeal cysts Naked nerve roots 

Notes

Compliance with ethical standards

Funding

No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Al-Brashdi YH, Raniga S, Revati SR (2013) Spontaneous intracranial hypotension with magnetic resonance localisation of spinal cerebrospinal fluid leak. Sultan Qaboos Univ Med J 13:E611–E615PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Albes G, Weng H, Horvath D, Musahl C, Bazner H, Henkes H (2012) Detection and treatment of spinal CSF leaks in idiopathic intracranial hypotension. Neuroradiology 54:1367–1373PubMedCrossRefGoogle Scholar
  3. 3.
    Aldrete JA (2004) Chronic adhesive arachnoiditis. Br J Anaesth 93:301, author reply 301–303PubMedCrossRefGoogle Scholar
  4. 4.
    Antony J, Hacking C, Jeffree RL (2015) Pachymeningeal enhancement—a comprehensive review of literature. Neurosurg Rev 38:649–659PubMedCrossRefGoogle Scholar
  5. 5.
    Beck J, Gralla J, Fung C, Ulrich CT, Schucht P, Fichtner J, Andereggen L, Gosau M, Hattingen E, Gutbrod K, Z’Graggen WJ, Reinert M, Husler J, Ozdoba C, Raabe A (2014) Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients. J Neurosurg 121:1380–1387PubMedCrossRefGoogle Scholar
  6. 6.
    Carlswärd C, Darvish B, Tunelli J, Irestedt L (2015) Chronic adhesive arachnoiditis after repeat epidural blood patch. Int J Obstet Anesth 24:280–283PubMedCrossRefGoogle Scholar
  7. 7.
    Chai CM, Banu MA, Cobb W, Mehta N, Heier L, Boockvar JA (2014) Novel hydrogel application in minimally invasive surgical approaches to spontaneous intracranial hypotension. Report of 2 cases. J Neurosurg 121:976–982PubMedCrossRefGoogle Scholar
  8. 8.
    Chazen JL, Talbott JF, Lantos JE, Dillon WP (2014) MR myelography for identification of spinal CSF leak in spontaneous intracranial hypotension. AJNR Am J Neuroradiol 35:2007–2012PubMedCrossRefGoogle Scholar
  9. 9.
    Cho KI, Moon HS, Jeon HJ, Park K, Kong DS (2011) Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch. Neurology 76:1139–1144PubMedCrossRefGoogle Scholar
  10. 10.
    Davis J, Yanny I, Chatu S, Dubois P, Hayee B, Moran N (2014) Spontaneous cerebrospinal fluid leak following a pilates class: a case report. J Med Case Rep 8:456PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Franzini A, Messina G, Chiapparini L, Bussone G (2013) Treatment of spontaneous intracranial hypotension: evolution of the therapeutic and diagnostic modalities. Neurol Sci 34(Suppl 1):S151–S155PubMedCrossRefGoogle Scholar
  12. 12.
    Gottschalk A (2015) Cerebrospinal fluid leakage. Indications, technique and results of treatment with a blood patch. Radiologe 55:471–478PubMedCrossRefGoogle Scholar
  13. 13.
    Hansen LB, Bjarkam CR (2014) Headache can be caused by spontaneous intracranial hypotension. Ugeskr Laeger 176(23). (in press)Google Scholar
  14. 14.
    Horikoshi T, Watanabe A, Uchida M, Kinouchi H (2010) Effectiveness of an epidural blood patch for patients with intracranial hypotension syndrome and persistent spinal epidural fluid collection after treatment. J Neurosurg 113:940–946PubMedCrossRefGoogle Scholar
  15. 15.
    Inamasu J, Guiot BH (2006) Intracranial hypotension with spinal pathology. Spine J 6:591–599PubMedCrossRefGoogle Scholar
  16. 16.
    Kranz PG, Gray L, Taylor JN (2011) CT-guided epidural blood patching of directly observed or potential leak sites for the targeted treatment of spontaneous intracranial hypotension. AJNR Am J Neuroradiol 32:832–838PubMedCrossRefGoogle Scholar
  17. 17.
    Kranz PG, Stinnett SS, Huang KT, Gray L (2013) Spinal meningeal diverticula in spontaneous intracranial hypotension: analysis of prevalence and myelographic appearance. AJNR Am J Neuroradiol 34:1284–1289PubMedCrossRefGoogle Scholar
  18. 18.
    Liu FC, Fuh JL, Wang YF, Wang SJ (2011) Connective tissue disorders in patients with spontaneous intracranial hypotension. Cephalalgia 31(6):691–695Google Scholar
  19. 19.
    Maher CO, Meyer FB, Mokri B (2000) Surgical treatment of spontaneous spinal cerebrospinal fluid leaks. Neurosurg Focus 9:e7PubMedCrossRefGoogle Scholar
  20. 20.
    Mokri B (2001) Spontaneous intracranial hypotension. Curr Pain Headache Rep 5:284–291PubMedCrossRefGoogle Scholar
  21. 21.
    Mokri B (2013) Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache 53:1034–1053PubMedCrossRefGoogle Scholar
  22. 22.
    Schievink WI (2000) Spontaneous spinal cerebrospinal fluid leaks: a review. Neurosurg Focus 9:e8PubMedCrossRefGoogle Scholar
  23. 23.
    Schievink WI (2006) Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 295:2286–2296PubMedCrossRefGoogle Scholar
  24. 24.
    Schievink WI (2008) Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia 28:1345–1356PubMedCrossRefGoogle Scholar
  25. 25.
    Schievink WI, Maya MM, Moser FM (2004) Treatment of spontaneous intracranial hypotension with percutaneous placement of a fibrin sealant. Report of four cases. J Neurosurg 100:1098–1100PubMedCrossRefGoogle Scholar
  26. 26.
    Spears RC (2014) Low-pressure/spinal fluid leak headache. Curr Pain Headache Rep 18:425PubMedCrossRefGoogle Scholar
  27. 27.
    Thielen KR, Sillery JC, Morris JM, Hoxworth JM, Diehn FE, Wald JT, Rosebrock RE, Yu L, Luetmer PH (2015) Ultrafast dynamic computed tomography myelography for the precise identification of high-flow cerebrospinal fluid leaks caused by spiculated spinal osteophytes. J Neurosurg Spine 22(3):324–331Google Scholar
  28. 28.
    Wang E, Wang D (2014) Successful treatment of spontaneous intracranial hypotension due to prominent cervical cerebrospinal fluid leak with cervical epidural blood patch. Pain Med 16(5):1013–1018PubMedCrossRefGoogle Scholar
  29. 29.
    Wendl CM, Schambach F, Zimmer C, Forschler A (2012) CT myelography for the planning and guidance of targeted epidural blood patches in patients with persistent spinal CSF leakage. AJNR Am J Neuroradiol 33:541–544PubMedCrossRefGoogle Scholar
  30. 30.
    Yoshida H, Takai K, Taniguchi M (2014) Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac. J Neurosurg Spine 21:432–441PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 2015

Authors and Affiliations

  1. 1.Department of Neurosurgery, Klinikum rechts der IsarTechnical University MunichMunichGermany

Personalised recommendations