Some studies from NERAC:

1. Epidural dextran-40 and paramethasone injection for treatment of spontaneous intracranial hypotension

Bel, I.; Moreno, L. -A.; Gomar, C.
Canadian Journal of Anesthesia, 53/6 (591-594), 2006
ISSN 0832-610X
Dr. I. Bel, Hospital Clinic, Department of Anesthesiology, Intensive Care and Pain Management, 170 Villarroel St., Barcelona 08036

Purpose: This report describes treatment with epidural dextran-40 and paramethasone injection of postural headache resulting from spontaneous intracranial hypotension in a pregnant patient. Clinical features: A 39-yr-old pregnant woman consulted the pain clinic for the assessment of a debilitating postural headache which was non-responsive to conventional analgesic treatment. Clinical findings and cranial magnetic resonance imaging indicated the diagnosis of spontaneous intracranial hypotension syndrome. Treatment with an epidural blood patch was not undertaken for several reasons. A lumbar epidural injection with dextran-40 and paramethasone led to a significant improvement in the symptoms and allowed a progressive discontinuation of adjuvant treatment with oral steroids, with complete resolution of symptoms. Conclusion: We report a case of spontaneous intracranial hypotension in a pregnant patient successfully treated by epidural injection of dextran-40 and paramethasone, with adjuvant oral steroid therapy. Clinical trials are warranted to establish the efficacy of this treatment as an alternative to the epidural blood patch administration.

2: Epidural blood patch at C2: Diagnosis and treatment of spontaneous intracranial hypotension

Rai, A.; Rosen, C.; Carpenter, J.; Miele, V.
American Journal of Neuroradiology, 26/10 (2663-2666),2005
ISSN-0195-6108
Dr. A. Rai, Department of Radiology, West Virginia University, PO Box 9235, Morgantown, WV 26506-9235

Spontaneous intracranial hypotension in a 37-year-old man with intractable headaches was diagnosed on MR imaging. A generous CSF leak was identified at C2 on CT myelography. Successful treatment was performed with CT-guided blood patch at the leakage site after the patient had failed 2 lumbar blood patches. Imaging-guided precise placement of the blood patch is safe and recommended when a lumbar blood patch away from the leakage site could be ineffective.

3: Spectrum of subdural fluid collections in spontaneous intracranial hypotension

Schievink, W. I.; Maya, M. M.; Moser, F. G.; Tourje, J.
Journal of Neurosurgery, 103/4 (608-613), 2005
ISSN-0022-3085; 0022-3085
Dr. W.I. Schievink, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 8631 West Third Street, Los Angeles, CA 90048

Object. Spontaneous intracranial hypotension is a noteworthy but commonly misdiagnosed cause of new daily persistent headaches. Subdural fluid collections are frequent radiographic findings, but they can be interpreted as primary rather than secondary pathological entities, and uncertainties exist regarding their optimal management. The authors therefore reviewed their experience with subdural fluid collections in 40 consecutive patients with spontaneous spinal cerebrospinal fluid (CSF) leaks and intracranial hypotension. Methods. The mean age of the 26 female and 14 male patients was 43 years (range 13-72 years). Subdural fluid collections were present in 20 patients (50%); 12 of these patients (60%) had subdural hygromas alone, and eight (40%) had subacute to chronic subdural hematomas (SDHs) associated with significant mass effect. The subdural hygromas resolved within several days to weeks following treatment of the underlying CSF leak. Three patients with SDHs underwent evacuation of the hematoma prior to the establishment of the diagnosis of spontaneous intracranial hypotension, but the SDHs did not resolve until the underlying spinal CSF leak was treated. In the remaining five patients, the CSF leak was treated primarily and the SDHs resolved over a 1- to 3-month period without the need for evacuation. Conclusions. Subdural fluid collections are common in spontaneous intracranial hypotension, varying in appearance from thin subdural hygromas to large SDHs associated with significant mass effect. These collections can be safely managed by directing treatment at the underlying CSF leak without the need for hematoma evacuation.

4: Clinical features and long-term results of spontaneous intracranial hypotension

Kong, D. -S.; Park, K.; Nam, D. H.; Lee, J. -I.; Kim, J. S.; Eoh, W.; Kim, J. H.
Neurosurgery, VOLUME 57, NUMBER 1, PP 91-95,2005
ISSN-0148-396X
Dr. K. Park, Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-gu, Seoul 135-710

OBJECTIVE: Although spontaneous intracranial hypotension (SIH) is an increasingly recognized syndrome, the long-term outcomes have not been established. We conducted a long-term follow-up study to clarify the clinical features and long-term outcomes of patients with this disorder.

METHODS: We performed a retrospective study in 13 consecutive patients with SIH treated between 1998 and 2003. The diagnosis of intracranial hypotension was made on the basis of clinical symptoms, lumbar puncture, radiological studies (e.g. brain magnetic resonance imaging, spine magnetic resonance imaging, computed tomographic myelography) and radionuclide cisternography. We collected follow-up clinical information of the patients by telephone or by examination at an outpatient clinic.

RESULTS: All patients were treated by nonsurgical conservative treatments, such as absolute bed rest, intravenous hydration and repetitive epidural blood patch (5 patients). The mean duration of follow up was 51.4 months (range, 15-80 mo). Among 13 patients included in this study, only one patient (7.7%) developed recurrent SIH, and the other patients improved from orthostatic headache. Although 7 of 13 patients had complete resolution of headache at a minimum of 2 years follow-up, 4 patients had mild headache and 2 patients continued to have moderate headache at the final examination.

CONCLUSION: In this series, the outcome of SIH after conservative treatment was not as satisfactory as that reported in previous studies. We conclude that periodic follow-up examinations must be performed and a more effective treatment modality developed to achieve complete resolution of SIH.