Clinical and radiological prognostic factors in spontaneous intracranial hypotension: a case series
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Clinical and radiological prognostic factors in spontaneous intracranial hypotension: a case series Umberto Pensato 1 & Cristina Russo 1 & Valentina Favoni 2 & Luigi Cirillo 1,2 & Gian Maria Asioli 1 & Pietro Cortelli 1,2 & Sabina Cevoli 2 & Giulia Pierangeli 1,2
# Fondazione Società Italiana di Neurologia 2020
Spontaneous intracranial hypotension (SIH) results from low cerebrospinal fluid (CSF) volume, typically secondary to a spinal CSF leak. CSF hypovolemia leads to brain sagging, particularly in orthostatic position, and expansion of the intracranial venous compartment. These pathophysiological mechanisms are responsible for the clinical presentation that usually consists of postural headache variably associated with other neurological symptoms. The wide range of clinical manifestations, including the absence of typical headache, may delay diagnosis. Magnetic resonance imaging (MRI) supports diagnosis showing typical findings including subdural fluid collections, pachymeningeal enhancement and brain sagging. Although SIH is historically considered a benign condition and neurological symptoms may be mild or even absent, its underlying pathophysiology predisposes to serious medical complications including cerebral venous thrombosis, intracranial haemorrhage, frontotemporal syndrome and coma. Thus, early diagnosis and appropriate treatment are paramount to prevent potential neurological sequelae. The epidural blood patch (EBP) is the gold standard treatment in those patients who have not responded to initial conservative management (resting, caffeine, analgesics and steroids). First EBP response rate in SIH patients can range from 36 to 90%, but epidemiological/clinical predictors of EPB response are still lacking. Moreover, even though various indirect quantitative measures evaluating downward stretching of
* Umberto Pensato [email protected] 1
Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
2
IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italia
the brain have been proposed as prognostic factors, inconsistent results have emerged among different studies. The aim of the current retrospective study was to describe the evolution of a cohort of SIH patients in order to identify epidemiological, clinical and neuroradiological predictive factors of EBP response. We included all consecutive adult patients who had been diagnosed with headache secondary to SIH at our Tertiary Headache Center between 2014 and 2019. Epidemiological, anamnestic, clinical and radiological data were collected from available clinical documentation. Brain and spine MRIs were re-examined by an experienced neuroradiologist. Indirect quantitative measures of brain sagging were evaluated: the pontomesencephalic angle (PMA), the angle between the vein of Galen and the straight sinus (vG/ SS), the mammillo-pontine distance (MPD) and the iter dislocation > 2 mm below the incisural line were calculated for each patient on preope
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