Kent D. Nelson

Orthostatic Headache Syndrome with Csf Leak Secondary To Bony Pathology of the Cervical Spine

The syndrome of orthostatic (low pressure) headaches is well described and most commonly occurs following deliberate violation of the dura (e.g. lumbar puncture). This syndrome can also occur spontaneously and results from the leakage of CSF. We describe three patients who suffered from spontaneous CSF leaks secondary to bony pathology of the cervical spine, and propose that this may be a more common aetiology than originally thought. Often these patients are difficult to manage medically, and surgery may be necessary for symptomatic relief.

Spontaneous CSF leak treated with percutaneous CT-guided fibrin glue

Gladstone et al.1 advocate sealing CSF leaks with CT-guided, targeted fibrin glue injections in patients with spontaneous intracranial hypotension (SIH). We agree that the injection should be made at the site of the leak as a distant epidural blood patch may often give only temporary relief. In our SIH patients, we obtained permanent sealing of the leak in 13 of 16 cases in which the CSF loss at a spinal root level was approached either by direct surgery (three successful cases) or by targeted percutaneous …

The Role of Digital Subtraction Myelography in the Diagnosis and Localization of Spontaneous Spinal CSF Leaks

OBJECTIVE The objective of our study was to review the clinical utility of digital subtraction myelography for the diagnosis of spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH) and those with superficial siderosis. MATERIALS AND METHODS Procedure logs from 2007 to 2011 were reviewed to identify cases in which digital subtraction myelography was performed to diagnose spinal CSF leaks. Electronic medical records were reviewed to obtain information regarding diagnosis and outcome. For patients to be included in the study, preprocedural spinal MRI had to show an extradural fluid collection spanning more than one vertebral level and postmyelographic CT had to confirm the presence of an active CSF leak. If digital subtraction myelography successfully showed the site of the CSF leak, the location was documented. RESULTS Eleven patients (seven men and four women; mean age, 49.0 years) underwent digital subtraction myelography during the study period. Six patients had SIH and five patients had superficial siderosis. The extradural fluid collection on spinal MRI averaged a length of 15.5 vertebral levels. Digital subtraction myelography successfully showed the site of the CSF leak in nine of the 11 patients, and all of the dural tears were located in the thoracic spine between T3 and T11. CONCLUSION Digital subtraction myelography is a valuable diagnostic tool for the localization of rapid spinal CSF leaks and should be considered in patients who are clinically suspected to have a dural tear that is accompanied by a longitudinally extensive extradural fluid collection on spinal MRI.

Localization of a Rapid CSF Leak with Digital Subtraction Myelography

SUMMARY: A 53-year-old woman with superficial siderosis underwent spinal MR imaging, which demonstrated a large cervicothoracic epidural fluid collection compatible with a CSF leak. Conventional and dynamic CT myelography failed to localize the dural tear because of rapid equilibration of myelographic contrast between the thecal sac and the extradural collection. The superior temporal resolution of digital subtraction myelography precisely localized the CSF leak preoperatively and led to the successful surgical correction of the dural tear.

Metastatic prostate carcinoma mimicking meningioma: case report and review of the literature.

Background:Intracranial dural-based lesions can be due to benign or malignant processes. Imaging characteristics cannot always discern between different pathologic conditions. A thorough clinical evaluation may reveal likely diagnostic possibilities. However, in certain cases, the etiology of the underlying lesion may require biopsy or resection to appropriately treat the patient. Review Summary:We report the case of a large dural-based adenocarcinoma of the prostate clinically and radiographically mimicking a meningioma. We review the history and physical evaluation of the patient and subsequent treatment and response. We discuss the implications of dural-based intracranial lesions in patients with prostate cancer and review the literature of dural metastases, including the pathogenesis, tumor types, and clinical presentations. Conclusion:The differential diagnosis of dural-based lesions in the brain varies from incidental and benign to symptomatic and malignant. Careful vigilance in patients with a history of cancer and presenting with new symptoms or imaging evidence of dural-based lesions is critically important to provide timely intervention.

Progressive cervical myelopathy secondary to chronic ventriculoperitoneal CSF overshunting

CSF hypovolemia typically causes orthostatic headache with or without nonlocalizing symptoms such as neck pain, nausea, aural fullness, and dizziness.1 Focal complications are rare and are usually secondary to subdural hematoma. We report findings from a patient with progressive cervical myelopathy associated with cord distortion due to dural thickening and tortuous venous dilation. Chronic CSF hypotension caused by excessive ventriculoperitoneal shunting seemed to be the primary etiology. A 72-year-old woman presented for evaluation of an undiagnosed gait disorder. Twenty-seven years earlier she underwent right suboccipital craniectomy and ventriculoperitoneal shunt placement for a posterior fossa meningioma. There was no tumor recurrence or shunt malfunction. Four years earlier, she noted the insidious onset of right lower extremity spastic monoparesis. During the year prior to presentation, she developed bilateral leg and right arm weakness, left upper extremity numbness, and urinary urge incontinence. She denied headache, neck and shoulder pain, and orthostatic symptoms. Examination revealed a moderately severe, right-predominant, asymmetric spastic quadriparesis with generalized hyperreflexia, bilateral extensor plantar responses, and mild …

Late Juvenlle-onset Krabbe's Disease

Krabbes disease is an autosomal recessive leukodystrophy characterized by a lack of galactocerebroside beta-galactosidase activity. In contrast to the classic early infantile-onset form of Krabbes disease, less recognized, late-onset variants exist. The authors present a case of late juvenile-onset Krabbes disease, including the associated magnetic resonance imaging (MRI) findings. Most patients with late-onset Krabbes disease present with visual loss due to optic atrophy. Associated gait abnormalities and parental consanguinity should increase the clinicians suspicion that a child may have late-onset Krabbes disease. Because of the prolonged survival in late-onset Krabbes disease, the recent development of bone marrow transplantation for these patient makes diagnosis of this disorder particularly important.

Refractory headaches due to multilevel thoracic cerebrospinal fluid leaks

Background:  Spontaneous cerebrospinal fluid leak is a well‐documented cause of postural headache. We report a medically refractory headache due to multilevel thoracic cerebrospinal fluid leaks.

Radiation-induced meningioma following radiation therapy for pituitary adenoma

The authors report the long-term result of treatment of a presumed pituitary adenoma with external-beam radiation therapy, which appears to be the development of a radiation-induced meningioma. Of the post radiation neoplasms that have been reported, meningiomas constitute a large proportion of these lesions.

Occult orthostatic headache.

A 39-year-old woman experienced a thunderclap headache accompanied by neck stiffness, nausea, and persistent vomiting. The headache was exquisitely sensitive to changes in position, with its severity dramatically decreasing when the patient assumed a recumbent position. Lumbar puncture revealed an opening pressure of 50 mm of water and normal cerebrospinal fluid (CSF) analyses. Saggital MR images of the spine demonstrated a faint suggestion of an extradural CSF collection just anterior to the cord at C6-T1 (Figure 1). Subsequent computed tomography (CT) myelography of the spine revealed a CSF leak extending from C6 to T2, along with a prominent bone spur and superimposed disc just to the right of midline at C7-T1 (Figure 2). She underwent anterior cervical discectomy/osteophytectomy at C7-T1, and at surgery, the C7-T1 disc-osteophyte complex was accompanied by a 3-mm tear in the dura. Submitted by Drs. Eric Eross, Department of Neurology; David Dodick, Department of Neurology; and Kent Nelson, Department of Neuroradiology, Mayo Clinic, Scottsdale, Arizona.