CSF pressure changes - the ups and downs

      Spontaneous intracranial hypotension (SIH) is characterized by an orthostatic headache caused by spontaneous spinal CSF leakage. MRI with contrast of brain typically shows diffuse pachymeningeal enhancement, pituitary enlargement, engorged dural sinuses and brain descent, as well as collapsed superior ophthalmic veins. The demonstration of CSF leaks provides important information for diagnosis and guides therapeutic interventions, and is usually carried out by using computed tomographic myelography (CTM), or a non-invasive radiation-free technique comparable to CTM, i.e. heavily T2-weighted magnetic resonance myelography. Spinal CSF leaks had been thought to reflect the location of dural defects, which is challenged by recent studies. The mainstay of treatment is epidural dural blood patching (EBP), and targeted EBPs are believed to be more effective than non-targeted ones. Predictors for responsiveness to the first EBP include the length of anterior epidural CSF collections, midbrain-pons angle, and the volume of EBPs. The most dreaded complication is cranial subdural hematoma (SDH), which occurs in about 20%. Early surgical drainage should be considered for those with SDH ≥ 10mm and decreased GCS; however, adequate treatment of CSF leakage should be attempted before surgical intervention.
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