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Dural sac shrinkage signs on magnetic resonance imaging at the thoracic level in spontaneous intracranial hypotension—its clinical significance

  • Original Article - CSF Circulation
  • Published:
Acta Neurochirurgica Aims and scope

Abstract

Background

Spontaneous intracranial hypotension (SIH) is secondary to a cerebrospinal fluid leak at the spinal level without obvious causative events. Several signs on brain and cervical spine magnetic resonance (MR) imaging (MRI) have been associated with SIH but can be equivocal or negative. This retrospective study sought to identify characteristic SIH signs on thoracic spinal MRI.

Methods

Cranial and spinal MR images of 27 consecutive patients with classic SIH symptoms, who eventually received epidural autologous blood patches (EBPs), were analyzed.

Results

The most prevalent findings on T2-weighted MRI at the thoracic level were anterior shift of the spinal cord (96.3%) and dorsal dura mater (81.5%), probably caused by dural sac shrinkage. These dural sac shrinkage signs (DSSS) were frequently accompanied by cerebrospinal fluid collection in the posterior epidural space (77.8%) and a prominent epidural venous plexus (77.8%). These findings disappeared in all six patients who underwent post-EBP spinal MRI. Dural enhancement and brain sagging were minimum or absent on the cranial MR images of seven patients, although DSSS were obvious in these seven patients. For 23 patients with SIH and 28 healthy volunteers, a diagnostic test using thoracic MRI was performed by 13 experts to validate the usefulness of DSSS. The median sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy of the DSSS were high (range, 0.913–0.931).

Conclusions

Detection of DSSS on thoracic MRI facilitates an SIH diagnosis without the use of invasive imaging modalities. The DSSS were positive even in patients in whom classic cranial MRI signs for SIH were equivocal or minimal.

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References

  1. Albayram S, Kilic F, Ozer H, Baghaki S, Kocer N, Islak C (2008) Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. AJNR Am J Neurorad 29:116–121

    Article  CAS  Google Scholar 

  2. Beck J, Ulrich CT, Fung C, Fichtner J, Seidel K, Fiechter M, Hsieh K, Murek M, Bervini D, Meier N, Mono ML, Mordasini P, Hewer E, Z’Graggen WJ, Gralla J, Raabe A (2016) Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension. Neurology 87:1220–1226

    Article  Google Scholar 

  3. Chiapparini L, Farina L, D’Incerti L, Erbetta A, Pareyson D, Carriero MR, Savoiardo M (2002) Spinal radiological findings in nine patients with spontaneous intracranial hypotension. Neuroradiology 44:143–152

    Article  CAS  Google Scholar 

  4. Dobrocky T, Grunder L, Breiding PS, Branca M, Limacher A, Mosimann PJ, Mordasini P, Zibold F, Haeni L, Jesse CM, Fung C, Raabe A, Ulrich CT, Gralla J, Beck J, Piechowiak EI (2019) Assessing spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension with a scoring system based on brain magnetic resonance imaging findings. JAMA Neurol 76:580–587

    Article  Google Scholar 

  5. Falatko SR, Kelkar P, Setty P, Tong D, Soo TM (2015) C1–C2 cryptic cerebrospinal fluid leak directly identified by pressurized radionuclide cisternography: case report and review of the literature. Surg Neuro Int 6:126

    Article  Google Scholar 

  6. Feletti A, d’Avella D, Wikkelsø C, Klinge P, Hellström P, Tans J, Kiefer M, Meier U, Lemcke J, Paternò V, Stieglitz L, Sames M, Saur K, Kordás M, Vitanovic D, Gabarrós A, Llarga F, Triffaux M, Tyberghien A, Juhler M, Laurell K (2019) Ventriculoperitoneal shunt complications in the European idiopathic normal pressure hydrocephalus multicenter study. Oper Neurosurg 17:97–102

    Article  Google Scholar 

  7. Hashizume K, Watanabe K, Kawaguchi M, Taoka T, Shinkai T, Furuya H (2012) Comparison of computed tomography myelography and radioisotope cisternography to detect cerebrospinal fluid leakage in spontaneous intracranial hypotension. Spine 37:237–242

    Article  Google Scholar 

  8. Headache Classification Committee of the International Headache Society (IHS) (2018) The international classification of headache disorders, 3rd edition. Cephalalgia 38:1–211

    Google Scholar 

  9. Hosoya T, Hatazawa J, Sato S, Kanoto M, Fukao A, Kayama T (2013) Floating dural sac sign is a sensitive magnetic resonance imaging finding of spinal cerebrospinal fluid leakage. Neurol Med Chir 53:207–212

    Article  Google Scholar 

  10. Jaraj D, Rabiei K, Marlow T, Jensen C, Skoog I, Wikkelsø C (2014) Prevalence of idiopathic normal-pressure hydrocephalus. Neurology 82:1449–1454

    Article  Google Scholar 

  11. Kawahara T, Awa R, Atsuchi M, Arita K (2019) Intraoperative use of cone-beam computed tomography for the safe epidural blood patch: technical case report. Surg Neuro Int 10:110

    Article  Google Scholar 

  12. Kazui H, Miyajima M, Mori E, Ishikawa M, SINPHONI-2 investigators (2015) Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): an open-label randomised trial. Lancet Neurol 14:585–594

    Article  Google Scholar 

  13. Kranz PG, Luetmer PH, Diehn FE, Amrhein TJ, Tanpitukpongse TP, Gray L (2016) Myelographic techniques for the detection of spinal CSF leaks in spontaneous intracranial hypotension. AJR Am J Roentgenol 206:8–19

    Article  Google Scholar 

  14. Lee MJ, Hung CJ (2019) The benefits of radiological imaging for postoperative orthostatic headache: a case report. BMC Med Imaging 19:61

    Article  Google Scholar 

  15. Levi V, Di Laurenzio NE, Franzini A, Tramacere I, Erbetta A, Chiapparini L, D’Amico D, Franzini A, Messina G (2019) Lumbar epidural blood patch: Effectiveness on orthostatic headache and MRI predictive factors in 101 consecutive patients affected by spontaneous intracranial hypotension. J Neurosurg 132:809–817

    Article  Google Scholar 

  16. Martín-Láez R, Caballero-Arzapalo H, López-Menéndez LÁ, Arango-Lasprilla JC, Vázquez-Barquero A (2015) Epidemiology of idiopathic normal pressure hydrocephalus: a systematic review of the literature. World Neurosurg 84:2002–2009

    Article  Google Scholar 

  17. Medina JH, Abrams K, Falcone S, Bhatia RG (2010) Spinal imaging findings in spontaneous intracranial hypotension. AJR Am J Roentgenol 195:459–464

    Article  Google Scholar 

  18. Miyajima M, Kazui H, Mori E, Ishikawa M, On behalf of the SINPHONI-2 investigators (2016) One-year outcome in patients with idiopathic normal-pressure hydrocephalus: comparison of lumboperitoneal shunt to ventriculoperitoneal shunt. J Neurosurg 125:1483–1492

    Article  Google Scholar 

  19. Mokri B (2001) The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology 56:1746–1748

    Article  CAS  Google Scholar 

  20. Mokri B (2013) Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache 53:1034–1053

    Article  Google Scholar 

  21. Rabin BM, Roychowdhury S, Meyer JR, Cohen BA, LaPat KD, Russell EJ (1998) Spontaneous intracranial hypotension: spinal MR findings. AJNR Am J Neurorad 19:1034–1039

    CAS  Google Scholar 

  22. Sayer FT, Bodelsson M, Larsson EM, Romner B (2006) Spontaneous intracranial hypotension resulting in coma: case report. Neurosurgery 59:204

    Article  Google Scholar 

  23. Schick U, Musahl C, Papke K (2010) Diagnostics and treatment of spontaneous intracranial hypotension. Minim Invasive Neurosurg 53:15–20

    Article  CAS  Google Scholar 

  24. Schievink WI, Meyer FB, Atkinson JL, Mokri B (1996) Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 84:598–605

    Article  CAS  Google Scholar 

  25. Schievink WI, Maya MM, Louy C, Moser FG, Tourje J (2008) Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neurorad 29:853–856

    Article  CAS  Google Scholar 

  26. Tardieu GG, Fisahn C, Loukas M, Moisi M, Chapman J, Oskouian RJ, Tubbs RS (2016) The epidural ligaments (of Hofmann): a comprehensive review of the literature. Cureus 8:779

    Google Scholar 

  27. Wang YF, Fuh JL, Lirng JF, Chen SP, Hseu SS, Wu JC, Wang SJ (2015) Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study. Brain 138:1492–1498

    Article  Google Scholar 

  28. Watanabe A, Horikoshi T, Uchida M, Koizumi H, Yagishita T, Kinouchi H (2009) Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neurorad 30:147–151

    Article  CAS  Google Scholar 

  29. Yagi T, Horikoshi T, Senbokuya N, Murayama H, Kinouchi H (2018) Distribution patterns of spinal epidural fluid in patients with spontaneous intracranial hypotension syndrome. Neurol Med Chir 58:212–218

    Article  Google Scholar 

  30. Yoon SH, Chung YS, Yoon BW, Kim JE, Paek SH, Kim DG (2011) Clinical experiences with spontaneous intracranial hypotension: a proposal of a diagnostic approach and treatment. Clin Neurol Neurosurg 113:373–379

    Article  Google Scholar 

  31. Yousry I, Förderreuther S, Moriggl B, Holtmannspötter M, Naidich TP, Straube A, Yousry TA (2001) Cervical MR imaging in postural headache: MR signs and pathophysiological implications. AJNR Am J Neurorad 22:1239–1250

    CAS  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge the experts who participated in the diagnostic test: Dr. Makoto Horinouchi, Dr. Takayuki Suzuki, Dr. Yukiko Motoyama, Dr. Masayuki Wakita, Dr. Satoshi Oyama, Dr. Koji Takasaki, Dr. Masasumi Gondo, Dr. Ayumi Taniguchi, Dr. Naoyuki Kitamura, Dr. Naoaki Kanda, Dr. Yushi Nagano, Dr. Akari Machida, and Dr. Tomohisa Okada. We also wish to thank Kagoshima-Haibunsha for giving productive comments on this manuscript and Editage (www.editage.com) for English language editing.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan

    Takashi Kawahara, Kazunori Arita, Shingo Fujio, Ryosuke Hanaya, Muhammad Kamil, Hirofumi Hirano, Hitoshi Yamahata & Koji Yoshimoto

  2. Department of Neurosurgery, Atsuchi Neurosurgical Hospital, Kagoshima, Japan

    Takashi Kawahara & Masamichi Atsuchi

  3. Department of Neurosurgery, Kagoshima City Hospital, Kagoshima, Japan

    Takashi Kawahara

  4. Department of Neurosurgery, Izumi Regional Medical Center, Akune, Japan

    Kazunori Arita & Tomohisa Okada

  5. Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA

    FM Moinuddin

  6. Department of Neurologic Surgery, Airlangga University, Surabaya, Indonesia

    Muhammad Kamil

  7. Diagnostic Imaging Center, Medical Network Systems, Hiroshima, Japan

    Naoyuki Kitamura

  8. Department of Neurology, Imamura General Hospital, Kagoshima, Japan

    Naoaki Kanda

Authors
  1. Takashi Kawahara
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  2. Kazunori Arita
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  3. Shingo Fujio
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  4. Ryosuke Hanaya
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  5. Masamichi Atsuchi
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  7. Muhammad Kamil
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  8. Tomohisa Okada
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  9. Hirofumi Hirano
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  12. Hitoshi Yamahata
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  13. Koji Yoshimoto
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Contributions

Conception and design: Kawahara, Arita, Yoshimoto.

Acquisition of data: Kawahara, Hanaya, Fujio, Atsuchi, Okada, Kitamura, Kanda, Yamahata.

Analysis and interpretation of data: Kawahara, FM Moinuddin, Kamil, Hirano, Yamahata.

Drafting the article: Kawahara, Arita, Hanaya.

Critically revising the article: FM Moinuddin, Yoshimoto.

Reviewed submitted version of manuscript: Arita, Yoshimoto.

Study supervision: Yoshimoto.

Corresponding author

Correspondence to Kazunori Arita.

Ethics declarations

Ethics approval and consent to participate

This non-interventional study was approved by the Medical Ethics Committee of Atsuchi Hospital (R2-2, October 21, 2020). This study was conducted in accordance with the Declaration of Helsinki as revised in 2000 and the Ethical Guidelines for Medical and Health Research Involving Human Subjects (effective on February 9, 2015) promulgated by the Ministry of Health, Labor, and Welfare of Japan. The requirement for obtaining informed patient consent was waived due to the noninvasive nature of this study. An opt-out option was offered to all patients. To protect patient privacy, all data were collected and anonymized for analysis in an unlinkable fashion.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject.

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This article is part of the Topical Collection on CSF Circulation

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Kawahara, T., Arita, K., Fujio, S. et al. Dural sac shrinkage signs on magnetic resonance imaging at the thoracic level in spontaneous intracranial hypotension—its clinical significance. Acta Neurochir 163, 2685–2694 (2021). https://doi.org/10.1007/s00701-021-04933-w

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  • DOI: https://doi.org/10.1007/s00701-021-04933-w

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