Intracranial Hypotension: Advice on Best Treatment

Middle age female patient diagnosed with Spontaneous intracranial hypotension.  Has multiple (approx 23) perineural cysts.  Has undergone several blood patches and artificial CSF infusions without relief.  Does anyone have any thoughts on other therapies, new techniques, experts in field.  Appreciate the input.

Intracranial Hypotension: Advice on Best Treatment
Michael Hollingshead • none

10 thoughts on “Intracranial Hypotension: Advice on Best Treatment

  • March 25, 2009 at 1:48 pm

    Here is a recent article on something that you may want to try on your patient. It seems to me that the problem is that she cannot be adequately treated as the site of CSF leak has not clearly been identified.

    J.M. Hoxworth, A.C. Patel, E.P. Bosch, and K.D. Nelson. Localization of a Rapid CSF Leak with Digital Subtraction Myelography. AJNR Am J Neuroradiol 2009 30: 516-519

  • July 14, 2009 at 1:01 pm

    Drs Linda Gray and Peter Kranz from Duke have experience in treating intracranial hypotension with CT-guided blood patching. In patients with low opening pressure, they perform a CT myelogram to identify sites of CSF leak and/or perineural cysts and then target these levels. Sometimes up to 12 sites including the LP site can be patched. The clinical response is really impressive. This work is in the process of being published.

  • July 14, 2009 at 2:17 pm

    Jenny, I am not sure that I understood your comment entirely, do you mean that blood patches may also be used to seal a nerve root sleeve cyst that is leaking CSF?

  • July 14, 2009 at 2:54 pm

    YES, that is precisely what she means. I commented on that last week … what happened to my comment on this thread?

  • July 15, 2009 at 7:54 am

    Maybe my comment was lost since it was my first time posting?

    At any rate, the OP had asked about experts in the field of SIH. My husband and I have first-hand experience with the following two physicians:

    Dr. Wouter Schievink, Neurosurgeon
    Cedars Sinai Medical Center, Los Angeles, CA

    Dr. Linda Gray (Gray-Leith), Neuroradiologist
    Duke University Medical Center, Durham, NC

    Both have extensive knowledge and experience treating patients with spontaneous and traumatic spinal fluid leaks and readily consult with other physicians seeking treatment for their patients. Dr. Schievink has a multidisciplinary team of doctors that treat leaks using flouroscopic-guided epidural blood patching, CT-guided fibrin patching, and if necessary, surgery to repair leaks (both nerve root sleeve leaks and other locations). Dr. Gray uses dynamic CT myelography to locate active leaks and patches individual leak sites, as well as empiric CT-guided blood patching (without the LP for myelography) on known traumatic leak locations.

    Both of these doctors are pioneering the treatment of patients who suffer intractable headache(s) from a cerebrospinal fluid leak. Both doctors are extremely knowledgeable, compassionate, and experienced.

    While neither my husband, nor myself, are in the medical field, we have received quite an education regarding CSF leaks and their treatment. We would equally recommend these physicians.

    Dr. Schievink has published numerous articles regarding SIH and treatment modalities and also teaches on the subject at conferences. Dr. Gray has not published her findings yet, but I too understand she is in the process. I believe she told me that she also teaches about this as well.

  • July 15, 2009 at 7:58 am

    So even if you do not see a leak but there is a perineural cyst they will inject every cyst?

  • July 15, 2009 at 9:01 am

    I don’t know. Imaging spinal fluid leaks is difficult at best. Dr. Gray could probably explain better how she does her procedure, but I believe that a patients’ intracranial pressure has to fall in a certain range for a nerve root sleeve cyst to leak (or any other leak location for that matter). If the opening pressure is too low, you won’t know which cysts are leaking. Elliot’s B Solution can be infused to raise ICP and look for leaks. But all of this is done while the patient is in CT. The dynamic CT myelogram is ‘live imaging’. Most myelograms are delayed scans and if a patients’ leak is large, the contrast may be gone. If the patients’ leak is slow or intermittent and their pressure is low, the locations won’t leak.

    Dr. Gray targets blood at the leak locations. I do not know if she patches a location that is not actively leaking. The doctor who patches for Dr. Schievink does a double high volume blood patch (thoracic and lumbar injection sites) on the dorsal side of the spine to get blood up and down the spine. If the spread is good and into the nerve root sleeves, this would conceivably patch cysts that aren’t leaking. When Dr. Schievink utilizes fibrin, it is directed at known leak locations from a post-myelogram (delayed) scan.

  • July 15, 2009 at 4:36 pm

    I was Dr Gray’s fellow and have been involved in several cases of blood patching for intracranial hypotension. Dr Peter Kranz is an attending at Duke who is also providing this service.

    The procedure is as follows.
    1. CT-guided lumbar puncture with patient in decubitus position. If opening pressure is low, contrast is injected into the thecal space for the myelogram (Elliot’s B solution can also be injected as per Laura above if the pressure is too low). The needle is removed and dynamic maneuvers distribute contrast to the c-spine region (patient is rolled, we lift the legs, arch the back).
    2. CT myelogram from c-spine to l-spine in the prone position is performed immediately. Waiting too long can decrease the sensitivity for detection of CSF leaks. The findings of CSF leak that can be patched are linear contrast leaks and epidural cystic contrast collections adjacent to nerve roots. These look like perineural cysts but are really tiny pools of CSF. Perineural cysts that we see on MRI in the lumbar spine are never patched. She rarely patches the lumbar spine. Indirect signs of CSF leak are epidural cysts in the spinal canal. Sometimes these can be very large and extend over several spinal levels.
    3. The levels of CSF leak are marked on the skin. The patient is prepped again. Under sterile technique we place a spinal needle under CT-guidance into the transforaminal epidural space (similar to doing a nerve root injection) and then inject 3 mls of the patient’s blood taken with the help of a nurse from a good IV cannula. I’ve seen up to 20 sites patched at a time.

    The improvement in symptoms and the changes on MRI before and after blood patch are very impressive. Some patients have been cured completely. Others are coming back for interval blood patching, but with good medium term relief.

  • July 16, 2009 at 8:28 am

    We too see a fair number of these patients at Mayo mostly through Dr. Bahram Mokri (neurology) and Dr. David Piepgras (neurosurgery) as well as a few other physicians. If they have an MRI already that shows a leak we do a regular CT myelgram, If the leak is to quick to find the source we do a digital subtraction myelogram on the angio table (which we now have flat panel CT capabilities on, so we do a CT at the same time after we see where the high flow leak is) as described by our colleagues at Mayo Scottsdale in AJNR. The we patch the sites we see leaking. We routinely do not patch perineural cyst that are not leaking. If we do not see a leak on the Conventional myelogram with or without raising the intrathecal pressure we bring them back for delayed imaging at 3 hours. If we still cannot find the leak we do MR gad myelogram also with delayed imaging if need be looking for slower leaks. As of now we are only patching sites that we see are actively leaking. I am curious to know what pressure do you raise them to when you inject solution into the thecal sac. Usually even with lower pressures, 13 cc of myelographic contrast brings them into the normal range. Do you bring them to a supranormal range until they get discomfort?

  • September 22, 2011 at 10:50 am

    Apart from all these kind of investigative work, the main aim should towards the intra-cranial hypotension, & cause of this could be a leak around the lesion or from the lesion I think the pt. should keep in head low position for some time, that may some time seal the leak whatever nature of it, head low position definitely rises the ICP, and this could be better option than infusing the artificial CSF.

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