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Syndrome of low cerebral spinal fluid (CSF) volume, secondary to CSF leakeage into the epidural space ( spinal m

CT Scan and MRI spinal imaging findings in Spontaneous Intracranial Hypotension : a case report Sérgio Cardoso Radiology Department - Hospitais Cuf Lisbon , Portugal.

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Syndrome of low cerebral spinal fluid (CSF) volume, secondary to CSF leakeage into the epidural space ( spinal m

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  1. CT Scanand MRI spinalimagingfindingsinSpontaneousIntracranialHypotension: a case reportSérgio CardosoRadiologyDepartment - Hospitais CufLisbon, Portugal

  2. Syndromeoflowcerebral spinalfluid (CSF) volume, secondary to CSF leakeageintotheepiduralspace (spinal meninges structuralweakness) No previoushistoryofsurgeryor lombar puncture; Presence of trivial traumatic events in 1/3 of patients No epidemiological data available ( annualincidence5/100.000 ) Affectsyoungandmiddle age individuals; female/male ratio 2:1 Variableclinicalpresentation ; postural headacheisthemostcommonmanifestation Delayindiagnosisisveryfrequent SpontaneousIntracranialHypotension(SIH)

  3. 34 yofemale Previouslyhealthy, with no relevantissuesinherpastmedicalhistory Suddenlyonsetofpermanentsevere, cervical painoneweekbeforefirstobservation, with no relieforexacerbationfeatures No othersymptoms, as headache, fever, systemic Inphysicalexaminationtheonlyfindingwassome degreeofneckstiffness, withotherwise normal physicalandneurologicalexamination Laboratorial workoutshowedno significantabnormalities (normal CRP, normal bloodcount, normal renal andhepaticfunction) Case Report

  4. Cervical Spine CT Scan (03/06/2010) Antero-lateral hyperdense epidural collection

  5. Brain MRI (03/06/2010) No abnormalfindings

  6. Spine MRI (03/06/2010) EPIDURAL HEMATOMA ? SPINAL AVM ? Spine MRI - spinalepiduralcollection - dilatedepiduralveins - enlargementofepiduralvenousplexus - duralenhancement

  7. SpinalAngiography • No spine AVM • No signsof medular compression • No clinicaldeterioration →conservativeattitude

  8. Spine MRI (30/06/2010) • TypicalneuroimagingfeaturesofSIH • - epiduralfluidcollections • duralsaccollapse-festoonedappearence • duralenhancement • epiduralvenousplexusdilatation- dilatedepiduralveins • -C1\C2 sign (absent)

  9. Dorsal and Lombar Spine MR (30/06/2010) • - collapseofduralsac • dilatationofepiduralvenousplexus

  10. BrainMRI (30/06/2010) • Typicalbrainneuroimagingfeaturesof SIH • Subduralfluidcollections • Enhancementofpachymeninges • Engorgemntofvenousstructures • Pituitaryhyperemia • Saggingofthebrain • → SEEPS

  11. CT Myelography(22/07/2010) Persistentsymptomswithconservativetherapy (bedrestandhydratation) → CT myelography Thedifferentialopacificationofthecalsacandthe ventral fluidcollection→signofcommunication Theexactlocationofthecommunicationcouldnotbedetermined

  12. EVOLUTION • Conservativemeasuresuneffective (bedrest, oral hydration, caffeine intake) • Epiduralblood patch (27/07/2010) → clinicalimprovement • SpineandBrain MR (24/08/2010) • 03/06/2010 • 24/08/2010 • 30/06/2010 • 24/08/2010 24/08/2010

  13. TakeHomeMessages • Spontaneousintracranialhypotension (SIH) isnotrare, butisstillunderdiagnosed • Clinicalandimagingfindings are widelyvariable • CT Myelographyisthestudyofchoice to identifythe CSF leak, butisnotalwaysnecessary to makethediagnosis • The role ofspinalimagingfindingsin SIH isnotwellestablished, butawareness to abnormalitiesatthislevelcanlead to anearlierdiagnosis

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