Useful Websites

[David Hosobuchi]

Use this thread for posting other websites relevent to this forum....:)

[PainInTheNeck]

Greetings!! I found you all today by a referral from "Concerned Gal". I found her at the website SpinalHeadaches.org. It is such a relief to me to find I am not alone.:)

[repeat leaker]

Here is a website that will allow you to search the database of journal articles using many search criteria.

Many of the journals will let you view the abstract, others you need to pay to view the entire article unless you can find it elsewhere online.

Paste this link into your browser to reach the site (note this link includes the search criteria I put in...you can change the criteria (for example put in "phrase" to narrow the search).....

http://highwire.stanford.edu/cgi/searchresults?andortopics=and&pubdate_year=&volume=&firstpage=&author1=&author2=&title=&titleabstract=&fulltext=spontaneous+csf+leak&andorexacttitle=and&andorexacttitleabs=&andorexactfulltext=and&src=hw&jc_favj=&fmonth=Jan&fyear=1844&tmonth=Dec&tyear=2007&flag=&RESULTFORMAT=1&hits=100&hitsbrief=&sortspec=relevance&sortspecbrief=&resourcetype=1&tdatedef=22+Dec+2006&fdatedef=1+January+1844&

[repeat leaker]

Many on this forum have asked about blood patch efficacy. I found this article that I thought would be very helpful, and it was free to access so I thought I would share.

For those of us having EPBs we may, based on this article, request that we lie down for a minimum of 2 hours. I know in my case I have had many blood patches, but not all, where the facility said I was free to go after a 1/2 hour.

Not sure if it is helpful...here goes (I will also post in the useful websites).

Another interesting point here "in the absence of CSF the coagulation process is four times slower". This is reinforcement to the theory that high volume blood injections are needed in CSF Leakers.

It may or not be helpful...but I thought it was interesting....

http://www.cja-jca.org/cgi/reprint/41/1/23

[LauraL840]

June 19, 2005
Epidural blood patch - myths and legends
http://www.cja-jca.org/cgi/content/full/52/suppl_1/R12

September 20, 1999
CT-Guided Percutaneous Fibrin Glue Therapy of Cerebrospinal Fluid Leaks in the Spine After Surgery
http://www.ajronline.org/cgi/content/full/175/2/443

[LauraL840]

I know this is a LOT of links ... it's one reason I hadn't posted them all because I find reading articles is sometimes overwhelming! There has been something useful, helpful or important in each of these articles that DH and I NEEDED to learn before 'taking on' the medical community! Doctors can be great, but they by no means, know everything! And some do a dismal job explaining themselves :eek: ....
I hope this stuff will be helpful to someone else!

Pretty COOL Search Engine
http://www.righthealth.com/


Intestinal Activity Visualized on Radionucide Cisternography in Patients with Cerebrospinal Fluid Leak
1991
http://jnm.snmjournals.org/cgi/reprint/32/1/151.pdf


Cerebrospinal Fluid Analysis
http://www.aafp.org/afp/20030915/1103.html


Spontaneous Spinal Cerebrospinal Fluid Leaks: A Review
Wouter I. Schievink, M.D.
Neurosurg Focus 9(1), 2000
http://www.medscape.com/viewarticle/405624_print


Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension
Wouter I. Schievink, MD
JAMA. 2006
This should open the full text version....
http://jama.ama-assn.org/cgi/content/full/295/19/2286


Cervical MR Imaging in Postural Headache: MR Signs and Pathophysiological Implications
2001
http://www.ajnr.org/cgi/content/full/22/7/1239


CT-Guided Percutaneous Fibrin Glue Therapy of Cerebrospinal Fluid Leaks in the Spine After Surgery
2000
http://www.ajronline.org/cgi/content/full/175/2/443


A Novel Absorbable Hydrogel for Dural Repair: Results of a Pilot Clinical Study
*Not sure of date on this, but it references articles from 2003
http://www.spraygel.com/pdf/ds/DuraSeal_Pilot_Study_WP4-7-05.pdf


Epidural blood patch - myths and legends
Sunday June 19 2005
http://www.cja-jca.org/cgi/content/full/52/suppl_1/R12


Lidocaine Inhibits Blood Coagulation: Implications for Epidural Blood Patch
1995
http://www.anesthesia-analgesia.org/cgi/reprint/82/4/766.pdf


Found this 'discussion and comments' from anesthesiologists interesting....
"Use of a 'blood patch' to treat severe headache due to cerebrospinal fluid leakage after epidural anesthesia"
http://www.cbbsweb.org/enf/2004/bloodpatch_epidural.html


Excellent article on 'wound sealants' ...
The Use of Autologous Platelet-Rich Plasma (Platelet Gel) and Autologous Platelet-Poor Plasma (Fibrin Glue) in Cosmetic Surgery
Jan 2001
http://www.drman.com/articles_details_11_the_use_of_autologous_platelet-rich_plasma.html


Composition and characteristics of an autologous thrombocyte gel
April 2004
http://www.journalofsurgicalresearch.com/article/PIIS0022480403007200/abstract


Interesting......
Fibrin glues of human origin
Dec 2005
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WBG-4HW3MPD-H&_user=10&_coverDate=03%2F31%2F2006&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=eb32d85155965b48b3322f27ea01d6cd


Evaluation of CSF Leaks: High-Resolution CT Compared with Contrast-Enhanced CT and Radionuclide Cisternography
1999
http://www.ajnr.org/cgi/content/full/20/4/706


Low Cerebrospinal Fluid Pressure Headache
2002
http://www.treatment-options.com/article.cfm?PubID=NE04-5-1-04&Type=Article&KeyWords=


Epidural dextran–40 and paramethasone injection for treatment of spontaneous intracranial hypotension
2006
http://www.cja-jca.org/cgi/content/abstract/53/6/591


Persistent Posttraumatic Cerebrospinal Fluid Leakage
**medscape article may require you to register (free) with medscape before viewing**
2000
http://www.medscape.com/viewarticle/405618_print


Postdural puncture headache in a parturient with sickle cell disease: use of an epidural colloid patch
2003
http://www.cja-jca.org/cgi/content/full/50/8/812


Post-dural puncture headache: pathogenesis, prevention and treatment
2004
http://bja.oxfordjournals.org/cgi/content/full/92/5/767


Surgical Treatment of Spontaneous Spinal Cerebrospinal Fluid Leaks
2000
http://www.medscape.com/viewarticle/405623_print


Treatment of Postdural Puncture Headaches with Colloid Solutions: An Alternative to Epidural Blood Patch
1999
http://www.anesthesia-analgesia.org/cgi/content/full/89/5/1333-a


Use of Intravenous Tetracosactin in the Treatment of Postdural Puncture Headache: Our Experience in Forty Cases
2002
http://www.anesthesia-analgesia.org/cgi/content/full/94/5/1369?ck=nck


Found this to be a helpful description...
Radionuclide cisternogram
http://www.drugs.com/enc/radionuclide-cisternogram.html

*sevendwarfs

[leidalsn]

A somewhat technical but thorough review:
Intracranial hypotension syndrome: a comprehensive review

http://www.aans.org/education/journal/neurosurgical/dec03/15-6-cp2.pdf

[LauraL840]

Another Mokri article:
Dynamic CT Myelography: A Technique for Localizing High-Flow Spinal Cerebrospinal Fluid Leaks

http://www.ajnr.org/cgi/content/full/24/8/1711?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=csf+leak&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

[LauraL840]

This may be worthwhile to some spontaneous ear leakers ....
Hyrtl’s Fissure: A Case of Spontaneous Cerebrospinal Fluid Otorrhea

http://www.ajnr.org/cgi/content/full/26/4/963?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=csf+leak&andorexactfulltext=and&searchid=1&FIRSTINDEX=10&sortspec=relevance&resourcetype=HWCIT

[LauraL840]

Cervical dural puncture and lumbar extradural blood patch

http://www.cja-jca.org/cgi/reprint/42/12/1143.pdf

[LauraL840]

The Effect of Fibrin Glue Patch in an In vitro Model of
Postdural Puncture Leakage


http://www.anesthesia-analgesia.org/cgi/reprint/87/5/1125.pdf

[LauraL840]

http://http://ats.ctsnetjournals.org/cgi/content/abstract/67/3/837

http://www.ncbi.nlm.nih.gov/sites/en...t=AbstractPlus

http://icvts.ctsnetjournals.org/cgi/content/full/5/1/25

http://www.scahq.org/sca3/newsletters/2005apr/lit3.shtml

http://www.anesthesiology.org/pt/re/...195629!8091!-1

[LauraL840]

This article discusses what TYPE of test can be done prior to RE-exposure of aprotinin (from bovine thrombin) which is one of the components in Tisseel (Baxter's fibrin product).

It's important, VITALLY important that if you do have a fibrin sealant used that you know WHAT kind was used if you need it used again! There are many 'types' of surgical sealants and several mfgs of fibrin products. Not all contain bovine thrombin or carry the risk of anaphylaxis from re-exposure to aprotinin, HOWEVER MANY of the sealants approved for exposure directly to the cranial-dura-csf areas DO contain bovine thrombin.

This may (or may not) apply to any leakers who have already had (unsuccessful) cranial leak repairs done; but if you are having fibrin used for a subsequent patch or repair, and HAVE had fibrin used in the past, the article will be helpful! Also, important to note is that the longer the time-frame between exposure, the less likely you are to have an allergic response - good news there anyway!


http://www.anesthesia-analgesia.org/cgi/content/abstract/90/2/262?ijkey=a121ec51f394022abc525f8688b4d2343f4a3b5a &keytype2=tf_ipsecsha

[LauraL840]

This article evaluated the differences between fibrin sealants, however it's European research, so you'll have to determine the US equivalents for the med manufacturers...
http://www.eahp.eu/upload/ejhp/p3-9.pdf

http://www.engr.sjsu.edu/wrchung/ima...alsealants.pdf


http://www.mediligence.com/rpt/sampl...e-rpt-s145.pdf
(this is a partial report, but still contains useful info)


And for a modest fee :rolleyes: $3750 you can purchase the report in full at:
http://www.mediligence.com/rpt/rpt-s145.htm

[nancydrewbr]

CSF Rhinorrhea (nose) leaks

I found this article to be helpful in detecting leaks and fairly current, 2004.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1151686

[nancydrewbr]

Very informative and current article on CSF leaks

http://www.emedicine.com/ent/topic332.htm

[nancydrewbr]

A good cerebrospinal fluid leak symptom list is in the following link:

http://www.nyp.org/health/cerebrospinal-fluid-leaks.html

I would add to this list:

* leaking nose ( can be slow trickle of fluid/ low volume to much greater)
* neck stiffness
* inflamed feeling
* lots of pain referring to ear
* feel very tired

You may have some of these, or a combination of these symptoms.

[nancydrewbr]

Another informative article on CSF leaks that I found helpful in the diagnosis, etc.

http://www.utmb.edu/otoref/Grnds/CS-Leak-021002/CF-leak-021002.htm

[LauraL840]

Cross posting this article so it will remain 'current' in the sticky thread.....

Relatively 'new' article regarding nontraumatic skull base defects and csf rhinorrhea.

Nontraumatic Skull Base Defects and CSF Rhinorrhea (http://www.ajnr.org/cgi/content/abstract/ajnr.A0840v1)

[LauraL840]

This is a great article from 2004 that does a nice job explaining different radiographic techniques for imaging CSF Rhinorrhea.
Radiological management of cerebrospinal fluid rhinorrhea (http://www.neurosciencesjournal.org/_cgi-bin/DetailArticle.asp?ArticleId=731)

[LauraL840]

January 17, 2008

Detection of CSF Leak in Spinal CSF Leak Syndrome Using MR Myelography: Correlation with Radioisotope Cisternography (http://www.ajnr.org/cgi/content/abstract/ajnr.A0920v1)

If you suspect a spinal leak and are going for the 'poke' (LP) for diagnostics, this might be the type of imaging for you!

[brain drain]

Wow..I just found this slide show for csf leaks/repair options & statistics...I think this sums up everything..at least gives you an outline of it all. I just wanted to contribute something here instead of always being a taker here. This is worth looking at.

http://www.utmb.edu/otoref/Grnds/CSF-rhinorrhea-061115/CSF-rhinorrhea-slides-061111.pdf

hope this helps others get a better understanding of it all too.

[LauraL840]

A Feb 7, 2008 article out of Cedars (Schievink, Maya, Louy, Moser, Tourje)

Diagnostic Criteria for Spontaneous Spinal CSF Leaks and Intracranial Hypotension
(http://www.ajnr.org/cgi/content/abstract/ajnr.A0956v1)

[Pinwheel]

Here is link to an article on intracranial hypertension.

http://www.steadyhealth.com/articles/Intracranial_Hypertension__Pseudotumor_Cerebri_a23 7_f0.html

[Pinwheel]

Here is an article on the temporal bone:)
http://www.emedicine.com/ent/topic471.htm

[Pinwheel]

Another article :)

http://webeye.ophth.uiowa.edu/ips/IIH/PSEUDOTU.HTM

[Pinwheel]

One last article :)

http://www.encyclopedia.com/doc/1G1-62871341.html

[LauraL840]

Here's a bunch of ear/nose/combo leak articles, both spontaneous and traumatic. Some are article abstracts, others are full case reports. If an article abstract sounds like it 'fits' for you, I'd print it off and take it to your doctor and ask him/her to get you the full article!

If you have one or the other or both, there's some good information contained within!

Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. (http://www.unboundmedicine.com/medline/ebm/record/15170277/full_citation/Management_of_cerebrospinal_fluid_leak_associated_ with_craniomaxillofacial_trauma_)

Tegmental Defects and Cerebrospinal Fluid Otorrhea (http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowFulltext&ProduktNr=224270&Ausgabe=228173&ArtikelNr=55705)

Diagnosis and management of spontaneous cerebrospinal fluid-middle ear effusion and otorrhea. (http://www.galenicom.com/ca/medline/article/15126733)

Cerebrospinal fluid otorhinorrhea due to cochlear dysplasias (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7V-4FKY8W7-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=d33ebeb282f5ec9ecbb85e39f425ed83)

Concurrent Spontaneous CSF Otorrhea and Rhinorrhea (http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=115458&Ausgabe=234381&ProduktNr=223840&filename=115458.pdf)

SURGICAL MANAGEMENT OF CSF OTORHINORRHEA FOLLOWING RETROSIGMOID REMOVAL OF CEREBELLOPONTINE ANGLE TUMORS. (http://www.otology-neurotology.com/pt/re/otoneuroto/abstract.00000455-199311000-00013.htm;jsessionid=HYsGpMdcwrccT1PW11C54K2wjTG2d L2cHqCCyQzJNWT5JR920Mzl!1759956393!181195629!8091!-1)

Surgical treatment of difficult cerebrospinal fluid otorhinorrhea (http://cat.inist.fr/?aModele=afficheN&cpsidt=3330378)

Peripetrosal arachnoid cysts. Otology and neuro-otology (http://www.co-otolaryngology.com/pt/re/cooto/abstract.00020840-200710000-00007.htm;jsessionid=HYnNhsTNVlg4pJqtsx4rH2tV6PTFT N7pLkzJQFns4tYhJyHTk3WL!-308549311!181195628!8091!-1)

Adult spontaneous CSF otorrhea : Correlation with radiographic empty sella (http://cat.inist.fr/?aModele=afficheN&cpsidt=17756875)

Spontaneous transtemporal CSF leakage: a study of 51 cases. (http://www.encyclopedia.com/doc/1G1-139471415.html)

Invasive Cerebrospinal Fluid Cysts and Cephaloceles of the Petrous Apex. Tumors of the Ear and Cranial Base (http://www.otology-neurotology.com/pt/re/otoneuroto/abstract.00129492-200612000-00018.htm;jsessionid=HZkcyRYBFQNJ23q0pNvBvnQr22990 7CLLxGdnHQPqyTZzDzl35w3!1759956393!181195629!8091!-1)

Petrous Apex Cephaloceles (http://www.ajnr.org/cgi/reprint/22/10/1867.pdf)

Idiopathic Temporal Bone Encephalocele (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2095123)

Petrous apex arachnoid cyst: a case report and review of the literature (http://www.actaitalica.it/issues/2005/5-05/achilli.pdf)

Petrous Apex Lesions (http://www.bcm.edu/oto/grand/03_09_06.htm)

Skull Base, Petrous Apex, Tumors (http://www.emedicine.com/ENT/topic244.htm)

Happy wading! Hope you can find a key that fits the lock!

[LauraL840]

(Cross-posted in it's own thread)

This is a bit more on the 'too technical' side for me; but I think noting the difference in this study (which images the chest) and applying it to brain and spine imaging in leakers is appropriate.

If ANYONE here is going for imaging of any type for their leak, please print this off and ask your doctor to discuss this with the neuroradiologist to see if this would produce a greater likelihood of SEEING a leak!

I'm going to paste the article overview in this post (it's relatively short) and then add the link for the ENTIRE article (with images) so if people want to print for their doc they can. I'm also going to cross-post this in useful links.

Multislice Helical CT of Focal and Diffuse Lung Disease: Comprehensive Diagnosis with Reconstruction of Contiguous and High-Resolution CT Sections from a Single Thin-Collimation Scan

OBJECTIVE. We tested breath-held 1-mm multislice helical CT for obtaining both contiguous and high-resolution CT sections of the chest from a single set of raw data.

SUBJECTS AND METHODS. Seventy patients with suspected focal and diffuse lung disease were allocated into two groups for comparison. The first group (n = 35) underwent multislice helical CT of the chest with 1-mm collimation and a pitch of 6. From the raw data, 5-mm contiguous and 1.25-mm high-resolution CT sections were reconstructed. The second group (n = 35) underwent conventional single-slice helical CT and high-resolution CT. High-resolution CT sections and 5-mm scans were rated for overall image quality, spatial resolution, subjective signal-to-noise ratio, diagnostic value, depiction of bronchi and parenchyma, and motion and streak artifacts. The 5-mm scans were also rated for contrast resolution and depiction of the heart and vessels. Radiation dose was calculated.

RESULTS. We rated 5-mm multislice helical CT superior to 5-mm single-slice helical CT, having a significantly higher total score (p = 0.0001). No significant difference (p = 0.986) was found between multislice and single-slice high-resolution CT sections. Radiation dose was 5.55 mSv for multislice helical CT and 5.50 mSv for single-slice helical CT.

CONCLUSION. Contiguous chest scans of superior quality and high-resolution CT sections of equal image quality compared with single-slice helical CT can be obtained using multislice helical CT. Therefore, a comprehensive diagnosis is feasible in patients with suspected focal and diffuse lung disease by obtaining a single scan.

Multislice Helical CT of Focal and Diffuse Lung Disease (http://www.ajronline.org/cgi/content/full/177/1/179)

[LauraL840]

Sellar reconstruction with resorbable vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients (http://www.aans.org/education/journal/neurosurgical/sep00/9-3-cp.pdf)

This should prove useful to cranial leakers, particularly ones who would be looking at transsphenoidal surgery and sellar reconstruction to repair a leak.

[LauraL840]

If you think your leak may be a result of a connective tissue disorder, or if you are unsure as to what a connective tissue disorder is, this is the site for you! It outlines major types of Ehlers Danlos and briefly discusses Marfan's and another type.

Ehlers-Danlos Syndrome, Classic Type (http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=gene.chapter.eds)

[LauraL840]

I don't recall if I have posted this link before, but came across this article again today. Good details on CSF leaks, imaging, treatment, etc. It's fairly recent 1/2007...

Cerebrospinal Fluid, Leak (http://www.emedicine.com/radio/topic139.htm)

Here's a HIGHLY technical article on Spinal MR Imaging ... it's on the old side 1999, but does a good job 'defining' types of MR images taken and which types are best for imaging different aspects of the spine.

Newer Sequences for Spinal MR Imaging: Smorgasbord or Succotash of Acronyms? (http://www.ajnr.org/cgi/content/full/20/3/361)

This is much newer 2/2007, very interesting and again, technical about spinal imaging:
Cutting Edge Imaging of THE Spine (http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2080848&blobtype=pdf)

This could be the ticket for spinal leakers if you can find a place that has one of these beauts' ...
Comparison of Dynamic™ Upright® MRI With Static Upright MRI
in More Than 1,000 Patients (http://www.fonar.com/news/111507.htm)

[LauraL840]

This site has great information on MR imaging only. It's a complex site, with lots of tabs to check into ... like a trip to Disney, you should plan on 'being there' for a while to get the full benefit! :)

Magnetic Resonance - Technology Information Portal (http://www.mr-tip.com/serv1.php?type=isimg)

[LauraL840]

Spontaneous intracranial hypotension with deep brain swelling (http://brain.oxfordjournals.org/cgi/content/full/130/7/1884)

May 2007 Article

[LauraL840]

This was posted on a thread, but I wanted to make sure it didn't disappear. It's a great article about the overlaying of High Resolution CT and MRI Cisternograms to locate a leak. It's a 2004 article. Props to the original poster 'moose53'!

Combined HRCT and MRI in the Detection of CSF Rhinorrhea (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1151686)

I found the commentary portion most interesting:

Morcos, Jacques J. (Department of Neurological Surgery, University of Miami, Miami, Florida).

Drs. Mostafa and Khafagi have reviewed their experience with the detection of cerebrospinal fluid (CSF) rhinorrhea and have suggested that fusing high-resolution coronal computed tomography (CT) images of the base of the skull with highly fat-suppressed T2-weighted magnetic resonance imaging (MRI) sequences might offer the best of both worlds, marrying high spatial resolution with the ability to visualize the continuity of CSF. Their success in 17 of 19 patients is impressive. One has to remember that the gold standard of CT Omnipaque studies is not particularly comfortable for patients, and the false-negative rate is appreciable. However, one must be cautious about performing CT and MRI in close temporal proximity. Furthermore, the angulation of the cuts must be similar to maximize accuracy of the fusion. I suspect, however, that in a larger series a certain degree of inaccuracy and misleading changes in the paranasal sinuses would still be encountered. In such cases, one could always refer to an intrathecal CT study.

In summary, this article is a valuable addition to the literature. I intend to try this technique at my institution to see if we can replicate these encouraging results.

[LauraL840]

Stumbling around online, found this beauty!

Detection of CSF Leak in Spinal CSF Leak Syndrome Using MR Myelography: Correlation with Radioisotope Cisternography (http://www.ajnr.org/cgi/content/abstract/29/4/649)

It's a January 2008 publication! Too bad it's only the abstract though, it would be great to read!

[LauraL840]

Looking for some other Schievink articles when I found this:

False localizing sign of C1–2 cerebrospinal fluid leak in spontaneous intracranial hypotension (http://jnsonline.org/jns/issues/v100n4/pdf/n1000639.pdf)

[LauraL840]

I don't know how long I've had this article bookmarked, but it's a GREAT 245-page article on pediatric chiari! I'm sure much of it applies to adult chiari as well, and may have some use here.

Pediatric Neurosurgery Chiari Malformation (http://www.portune.com/erin/chiari-info.pdf)

[LauraL840]

Trendelenburg Position: A Tool to Screen for the Presence of a Low CSF Pressure Syndrome in Daily Headache Patients (http://www.blackwell-synergy.com/doi/abs/10.1111/j.1526-4610.2007.01027.x)

[LauraL840]

From the American Journal of Neuroradiology 2001. Interesting observations on these 'spinal manifestations' and the type(s) and methods of imaging used.
Spinal Manifestations of Intracranial Hypotension (http://www.ajnr.org/cgi/content/full/22/7/1233)

[LauraL840]

Pay particular attention to the wording in this article about the use of Dynamic CT and injection of contrast agent DURING the scan to localize a CSF leak. This would technically work best with someone who has a high flow or high volume leak.

Neuroscience at UCSF Medical Center - Medical Mystery (http://www.ucsfhealth.org/common/pubs/neuroscience/spring2005/medmyst/)

The article also has links to two of the doctors mentioned in it. A third doctor, Dr. Robert Fishman, has been mentioned by Dr. Schievink as knowledgeable regarding CSF leaks.

[horseaholic]

Laura,

thanks for the info on this. Dr. Mokri had said that I was going to have to have one of these in order to directly pinpoint my leak (anywhere from T4 to T6) and no one could explain to me around here exactly what that was.

This guys leak was also where mine is!!! 10 hour surgery sounds scary. Also, my radiologist here did not want to do a blood patch where mine is due to the tight space. He said it would be very painful as there's barely enough space for the needle to go in.

I'm between a rock and a hard place as I'm feeling sooooo much better but not completely healed. Can't decide whether to have another blood patch in the lumbar area or just try and be patient.

Debi

[LauraL840]

"SAGGING BRAIN" CASE DRAMATIZES IMPORTANCE OF EXHAUSTIVE NEUROLOGICAL EXAMS IN PATIENTS WITH PUZZLING CONDITIONS (http://pub.ucsf.edu/newsservices/releases/2004010945/?print)

01 July 1998

"SAGGING BRAIN" CASE DRAMATIZES IMPORTANCE OF EXHAUSTIVE NEUROLOGICAL EXAMS IN PATIENTS WITH PUZZLING CONDITIONS

The successful treatment of a man ultimately diagnosed as having a condition known as "sagging brain" demonstrates the importance of exhaustive neurological scrutiny before concluding that a patient has an untreatable brain disorder, according to a UC San Francisco neurologist who presented the patient's case in the June issue of Neurology.

The report chronicles the tribulations of a 51-year-old Sacramento, Calif., computer programmer in otherwise excellent health whom neurologists were unable to treat.

Physicians in the man's hometown had conducted an MRI (magnetic resonance imaging) scan of his brain that suggested he had spontaneous intracranial hypotension, or "sagging brain," the result of a hole or tear in the sac around the spinal cord that causes fluid to leak into surrounding tissue. The resulting loss of pressure in the sac causes headaches and other symptoms such as visual abnormalities and the auditory disorder tinnitus, characterized by a ringing in the ear. Such tears to the spinal fluid sac are not uncommon following spinal taps or other forms of neurosurgery. They can also occur when otherwise benign cysts at the juncture of the sac and a surrounding nerve rupture.

In many people the hole repairs itself and the symptoms go away. In most other cases, injection of some of the patient's own blood into the space around the spine--in what is known as an epidural blood patch--ultimately allows the sac to heal. (The patch leads to a temporary blood clot, which allows time for the sac wall to permanently repair itself.)

In this case, the patient was given an epidural blood patch, and his headache went away. But three days later it was back. The physicians applied another epidural blood patch, but to no avail.

The patient began to get worse, with a declining level of consciousness, memory problems and incontinence. In an attempt to locate the site of a suspected spinal fluid leak, the physicians conducted a myelogram, in which X-rays are taken after injecting a dye into the sac surrounding the spinal cord. They found no hole, yet a repeat MRI continued to indicate characteristics of the "sagging brain" disorder. They injected another epidural blood patch, this time a high volume infusion, which failed to provide relief.

Given the patient's failing cognitive ability--heretofore uncharacteristic of the condition--and the failure to correct the suspected hole, the physicians were concerned that their original diagnosis had been incorrect. They suspected that he had an infectious or inflammatory process, such as encephalitis, in which the brain becomes inflamed, but they were unable to make a definitive diagnosis. It was at this point that the man was admitted to a convalescent home where his condition deteriorated.

The patient's partner, unwilling to accept his advancing decline, sought counsel at UCSF, far from home and outside the couple's insurance plan. The woman originally took her partner to the UCSF Stanford Health Care Memory Disorders Clinic, which is staffed by neurologists who are trained to evaluate cognitive dysfunction and are involved in clinical research on causes of dementia.

From there, she was referred to the UCSF Neurology Service, where she received advice from Robert Fishman, MD, a UCSF professor of neurology, who has seen 25 cases of this extremely rare syndrome (only 50 cases have been reported in the last 10 years). At this point, the scrutiny intensified.

The UCSF team conducted another MRI scan, which suggested that the original diagnosis, spontaneous intracranial hypotension, was correct and that the patient had a particularly severe case. "His brain was pulled down through the opening in the bottom of the skull, squeezing the portion of the brain involved in keeping him awake and alert," said Samuel Pleasure, MD, PhD, then chief resident of the neurology service and now an adjunct instructor of neurology at UCSF.

"He didn't lose consciousness--he wasn't in a coma, but he was inattentive and apathetic all the time. If he woke up, he might say a word or two or make a gesture, then drift off. Occasionally he would get up and walk out to the nurse's station."

In an attempt to temporarily treat the loss of spinal fluid pressure causing the patient's symptoms, the physicians administered an alternative to the epidural blood patch, a saline solution transmitted through a plastic tube to the space around his spine.

"Within six hours, he was strikingly more alert and interactive," Pleasure said. "By the next morning, he was almost normal, except for some memory problems. He woke up and said, `Where am I? What's going on?' Then he asked for a beer."

A computerized tomography (CT) myelogram and an MRI of the entire spine failed to demonstrate a spinal fluid leak. Following the failure to locate a leak, the patient was given another high volume blood patch, and subsequently became alert and had no symptoms other than mild memory deficits. He was sent home. A week later, the headache was back, along with some confusion. His ability to perform normal activities began to decline again.

William Dillon, MD, a UCSF professor of radiology, neurology and neurosurgery and one of the leading experts in the world on the radiology of the "sagging brain" disorder, examined the man's tests and after unusual investigation found a suspicious area. Another myelogram was performed focusing on that area and the leak was found. Another blood patch failed to reverse the leakage and the patient was taken to surgery where a ruptured cyst was identified.

"The hole caused by the cyst was closed through surgery, and the patient completely recovered," said Pleasure. "He's back to work as a computer programmer and his memory is back to normal." The message here, said Pleasure, is that patients and their families should advocate for the most advanced neurological examinations possible when there is an unclear diagnosis so that these "odd ball cases don't get missed." "It is unclear whether the case we describe, involving cognitive decline and a nearly indiscernible cyst, is the first that has ever occurred or whether it occurs more commonly and has simply not been diagnosed accurately. "Regardless," he said, "there are many neurological disorders that may mimic the more common causes of dementia that simply don't get diagnosed accurately. A minority may be treatable. But even in the cases where they aren't, it is better to have an accurate diagnosis."

"Neurologists need to know about this syndrome, and other physicians need to remember that many causes of cognitive dysfunction are treatable," said Pleasure.

"If this man's partner hadn't pushed for some kind of answer, I don't know where he would be right now."

When the patient returned to UCSF for a meeting several months after his July 1996 surgery, he brought the nurses and physicians the homemade cheesecake he'd spoken of while a patient, as well as two six packs of beer.

"The only headaches I get now are from hangovers," he joked.

[Concerned Gal]

good golly! A convalescent home..... :eek:

All it took as a Dr who spent the time to sit there and search and hey presto, an abnormality appears.

[LauraL840]

I scanned in their business cards so their contact information is available. Dr. Schievink's direct email is posted online under articles he's written, so that already makes it pretty public....

It's:Wouter.Schievink@cshs.org

http://im1.shutterfly.com/media/47b8d732b3127ccec54f1fe5237800000040O00BcsmjVs1ZMg e3nwI/cC/f%3D0/ps%3D50/r%3D0/rx%3D480/ry%3D320/

[vini]

hi all this is handy real simple to use

http://www.shrinkpictures.com/

[nancydrewbr]

A good site for anyone with a possible ear leak or perilymph fistula/PLF.

Find a doc or info all over the world. www.vestibular.org

[LauraL840]

Cross-posting an article from May 2008:

Repair Spontaneous CSF Leaks Firmly to Avoid Recurrence (http://www.entoday.com/pt/re/entoday/fulltext.01265117-200805000-00004.htm;jsessionid=JmBJJfVXJyLZ7QVxDV3MxcCC3WkQk X0kvHCwhyYMF0QbLJyYQWxc!1945311642!181195628!8091!-1)

[LauraL840]

I was going to post a link to this earlier, but figured it would be as frustrating to everyone here as it was for me. This article is way above my knowledge base and too technical for me to grasp the entirety of the information within. I 'struggled' through the parts that I thought were useful and long enough to determine that Dr. Schievink could do 'more' with it than I could ever dream! So I sent him a link to the copy telling him it was 'way over my head' but perhaps he'd find it useful. His reply was that it was 'actually a good article'. So, here is the link!

Sorry if it's too technical ... perhaps someone with a better knowledge base in medicine can decipher what's relevant and translate it for us! It's fairly new - May 2008

Multiplicity of cerebrospinal fluid functions: New challenges in health and disease (http://www.cerebrospinalfluidresearch.com/content/5/1/10)

[LauraL840]

May 2008 Article

Repair Spontaneous CSF Leaks Firmly to Avoid Recurrence (http://www.entoday.com/pt/re/entoday/fulltext.01265117-200805000-00004.htm;jsessionid=JDQP9qy2L2ycWPnJVf7XM0BKdTVDP TM92pB9Hv1bjJXyzQ8FJm6j!-595418120!181195629!8091!-1)

[LauraL840]

My Headache Does Not Get Better When I Lie Down: Spontaneous Intracranial Hypotension Complicated by Venous Thrombosis (http://www3.interscience.wiley.com/cgi-bin/fulltext/119390620/HTMLSTART)

[LauraL840]

Orthostatic headache without CSF leak (http://www.neurology.org/cgi/content/short/71/23/1902)

Dec 2008 Mokri article

[LauraL840]

Found these two articles this morning. They are a bit dated (1998 and 2002) however they contain interesting information regarding orthostatic head and neck pain. I know some/several leakers HAVE neck pain with leaks in L-spine and T-spine, so I found it interesting that both these studies discuss this concept. Have to wonder if many of these patients had leaks as I didn't see CSF leaks as a category of injury in the patients reviewed....

The prevalence and association of neck (coat-hanger) pain and orthostatic (postural) hypotension in human spinal cord injury - 2002 (http://www.nature.com/sc/journal/v40/n2/pdf/3101259a.pdf)

Neck and other muscle pains in autonomic failure: their association with orthostatic hypotension - 1998 (http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1296807&blobtype=pdf)

[LauraL840]

In the interest of presenting a concise collection of information regarding the aforementioned topic, I am collecting all the links previously posted and placing them all into this new 'sticky' post. ;)

Sorry for the ambiguous thread title. I really am not sure how to title it and am not sure where it's going! LOL I am also going to apologize, in advance, for the LENGTH! It's a multiple-meal digestion process I am sure!

There have been several threads recently and in the past (months) discussing different terms, diagnosis, etc on issues such as Chiari, cerebellar tonsil descent, tonsillar herniation, pseudotumor cerebri (PTC), basilar invagination, hindbrain herniation, etc.

So I've been reading for (months) what seems like forever on some of these issues and looking at their similarities, differences, causes, treatments, complicating factors, etc. And while I am not really sure if there are dots to connect anywhere; I think there might be pieces of puzzles contained in all this that apply for some people here.

Almost all, if not all, of the terms I listed above cause (or can cause depending on severity) complications or problems with the cerebrospinal fluid FLOW around the brain and into the spinal cord.

I am going to try to post links for all the articles and sites that have provided interesting or useful information regarding these issues in this thread. One thing I am almost convinced of is the possibility of some type of ICP 'duality' existing for some leakers.

Let me see if I can explain my 'theory' and at some point provide the links that may support it. I will use an example; patient X develops spinal level CSF leak from a rent large enough to lose fluid at a substantial rate. This resulting loss of fluid causes the brain to 'settle' and is often (for leakers) called cerebellar tonsilar descent. If the cerebellar tonsils descend low enough, CSF flow around the brain is obstructed, perhaps almost completely blocking the flow of CSF from the brain into the spinal column. SO, patient X could possibly experience a 'duality' of symptoms (theory here) ... low to ZERO opening pressures due to the rent and orthostatic headaches, but also maintain HIGH PRESSURE headaches and some ambiguity of symptoms due to the obstruction of CSF flow.

Some CSF is produced in the spine, but most is produced in the brain and flows through the ventricals, around the brain, and into the spine. Plus, there are a whole HOST of symptoms that are attributable to brain-stem compression (regardless of the CAUSE, although some symptoms indicated one cause more so than another) that may further complicate accurate diagnosis and treatment.

Other thoughts I have include a 'which came first' issue that I mull over frequently. Clearly for MANY leakers there is an underlying connective tissue disorder and for other leakers, there is an underlying or causative disorder or deformity that creates a leak. However, I think there may be some people who develop leaks as a result of an undiagnosed disorder/deformity WHO WERE ASYMPTOMATIC regarding their disorder/deformity until the leak developed.

Again, I am not sure where all this is going, perhaps with some of you in the form of questions for your doctors? Clearly there are many leakers who have multiple complicating or aggravating factors and resolution of issues and restoration of health may be crucially dependent upon the discovery/discernment of which issue to treat and 'resolve' first ... or rather 'what do we do first, second, third, etc in order to create the best possible outcome?'

So here go some of the links that provide interesting definitions and interpretations along with symptoms for different diagnosis:

UCLA Chiari Malformation (http://neurosurgery.ucla.edu/body.cfm?id=126)
This site actually lists some of the 'less' common causes of Chiari that are not congenital. Let me quote:

What causes a Chiari malformation

* In many cases it is congenital (present at birth). Researchers at UCLA discovered that in most cases the compartment of the brain holding the cerebellum (posterior fossa) is smaller than normal.

* If the upper certical vertebra (odontoid process of the second cervical vertebra) ascends into the cranial compartment (basilar invagination), the canal at the junction between the brain and spine can narrow.

* In rare instances high pressure in the brain compartment can “squeeze” the cerebellar tonsils downward. The condition may be associated with the following conditions:
o Pseudotumor cerebr.
o Hydrocephalus (typically due to aqueductal stenosis).
o Brain tumors in the cerebellum.
o Posterior fossa arachnoid cyst.

* In other rare instances, abnormally low pressure in the spinal compartment can “draw” the cerebellar tonsils downward. This can occur in association with the following circumstances:
o Lumboperitoneal shunt.
o Spontaneous intracranial hypotension.

This site may take a while to load, but I found it chock full of information, images (not for faint of heart), explanations, etc... This views like a Power Point presentation and is through UCLA
Different Architectural Types of Posterior Fossa Anatomy Seen in Chiari Patients; Implications for Treatment Strategies (http://www.syringomyelie.fr/IMG/swf_08.swf)

From Cedars Sinai:
Basilar Invagination (http://www.csmc.edu/5722.html)

From the 'Dizziness and Balance' good Dr. Hain gives an excellent overview and definition:
Basilar Invagination, Basilar Impression and Atlantoaxial Subluxation (http://www.dizziness-and-balance.com/disorders/central/cerebellar/basilar%20invagination.htm)

Interesting information contained on this site (Conquer Chiari), as well as good definitions for many of the medical terms:
It Can Be Hard To Get A Good Night's Sleep With Chiari... (http://www.conquerchiari.org/subs%20only/Volume%202/Issue%202(2)/Sleep%20Disturbances%202(2).asp)

Article out of UK:
Platybasia and Basilar Invagination (http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=000102172&Ausgabe=233100&ProduktNr=223840&filename=000102172.pdf)

From the American Journal of Neuroradiology, this article comes out of; The George Washington University Medical Center, National Institutes of Neurological Diseases and Stroke, and National Institutes of Health
MR Identification of Chiari Pathophysiology by Using Spatial and Temporal CSF Flow Indices and Implications for Syringomyelia (http://www.ajnr.org/cgi/content/full/24/2/165)

Neurosurgery Online gives access only to the abstract of the following, but still, potentially of interest;
Correlation of Cerebrospinal Fluid Flow Dynamics and Headache in Chiari I Malformation (http://journals.lww.com/neurosurgery/Abstract/2005/04000/Correlation_of_Cerebrospinal_Fluid_Flow_Dynamics.1 2.aspx)

From one of what I consider the BEST research sites, Cerebrospinal Fluid Research comes the following;
A unifying hypothesis for hydrocephalus, Chiari malformation, syringomyelia, anencephaly and spina bifida (http://www.cerebrospinalfluidresearch.com/content/5/1/7)

Journal article abstract only from UK;
Chiari I malformation without hydrocephalus: acute intracranial hypertension managed with endoscopic third ventriculostomy (ETV) (http://www.springerlink.com/content/x54j0l4n89143331/)

I am pretty sure I have a bunch of links 'buried' in sub-folders in my bookmarks that I've saved to review later that address some of these topics as well. But for that I'll have to add later, because my kids and the DAY is calling me! LOL


Found another article I'd archived in a temporary bookmarks folder. This one is from Journal of Neurosurgery:
Chiari-like tonsillar herniation associated with intracranial hypotension in Marfan syndrome
Case report (http://thejns.org/doi/abs/10.3171/ped.2007.106.1.48)

Another Journal of Neurosurgery article from the ole' archives... this one from 2008.

Craniocervical junction fusions in patients with hindbrain herniation and syringohydromyelia (http://thejns.org/doi/full/10.3171/SPI/2008/9/7/001?prevSearch=allfield%3A%20cerebellar+tonsillar+ herniation%20#8163277793040306256)

Perhaps a little more loosely associated with this thread, but the patient had IIH - idiopathic intracranial hypertension (sometimes called pseudotumor cerebri), then had a lumboperitoneal shunt placed that leaked.

Intracranial hypotension caused by leakage of cerebrospinal
fluid from the thecal sac after lumboperitoneal shunt
placement (ftp://128.218.19.39/Liao,Dillon,Chin,McDermott,Horton(2007).pdf)

This one is another abstract only:
Acquired Tonsillar Herniation and Syringomyelia After Pleural Effusion Aspiration: Case Report (http://journals.lww.com/neurosurgery/pages/articleviewer.aspx?year=2008&issue=05000&article=00024&type=abstract)


Found this one to be pretty interesting, a different use entirely for intrathecal saline infustion! It's also a 'case report' or abstract.

Intrathecal Saline Infusion in the Treatment of Obtundation Associated with Spontaneous Intracranial Hypotension: Technical Case Report (http://journals.lww.com/neurosurgery/pages/articleviewer.aspx?year=2002&issue=09000&article=00045&type=abstract)

Would love to have access to the full article, but here's the abstract, none-the-less:

Cranial venous outflow obstruction in the pseudotumour syndrome: incidence, nature and relevance (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WHP-466CGDW-B&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=4273c067b333dcd98616156d860698f4)

Has a few interesting points, but all in all is a great article detailing anatomy and physiology;
CRANIAL CAVITY & BLOOD VESSELS: CLINICAL CORRELATIONS (http://filer.case.edu/vxs33/Case%20Med/Year%202/Nervous%20System/Head%20&%20Neck%20Anatomy/Mcquarrie%2520hard%2520copy.pdf)

This article draws a similar correlation to my 'theory'. However, it's pretty old when it comes to what's considered current. SO, I'll keep digging, but think there may be something to consider anyway.

Simultaneous cerebral and spinal fluid pressure recordings. 2. Cerebrospinal dissociation with lesions at the foramen magnum. (http://www.ncbi.nlm.nih.gov/pubmed/7315557)

Pages 78-79 of this book contain the essence of my 'theory', however it's application is discussed solely in relation to syrinx. I do not know if it could cross into other disorders, but it's interesting none-the-less. I'm not sure how much of the book is available online. SO you may be able to read more detail further on, I just don't know.

Spinal Cord Diseases (http://books.google.com/books?id=ojl_7JZNkokC&pg=PA78&lpg=PA78&dq=cranial+csf+obstruction&source=bl&ots=3z959yl5wL&sig=xJetY0dyFhGFEc15C8SD0lCW4MQ&hl=en&ei=WZrFScqAHJnNmQek6uHcCw&sa=X&oi=book_result&resnum=10&ct=result#PPA78,M1)

This article, while not LEAK related, discusses similar symptoms in regards to fibromyalgia and either Chiari and/or cervical spinal cord compression/stenosis. There are A LOT of the same symptoms that leakers exhibit. Clearly a positional headache is more indicative of a leak, however MANY leakers do not necessarily present with positional headaches, particularly if they've leaked for some time.

Clinical evidence for cervical myelopathy due to Chiari malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia. (http://www.ncbi.nlm.nih.gov/pubmed/15083352?dopt=Abstract)

PS - interestingly enough this is also a Dr. Heffez article

Found a few articles (abstracts only) with interesting correlations. I'm going to post the links, but also quote the abstracts since they're relatively short.

The Chiari pseudotumor cerebri syndrome: symptom recurrence after decompressive surgery for Chiari malformation type I. (http://www.ncbi.nlm.nih.gov/pubmed/16357496?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed)

INTRODUCTION: The etiology of Chiari malformation type I (CM1) as well as other anomalies associated with CM1 remains poorly defined. We have noted the presence of elevated CSF pressures with small ventricles, consistent with the pseudotumor cerebri (PTC) syndrome in a group of CM1 patients that did not respond over the long term to posterior fossa decompression. In order to better understand this association, we reviewed a series of CM1 patients treated by posterior fossa decompression to define the prevalence and nature of post-Chiari PTC.

METHODS: We performed a retrospective chart review of 192 patients diagnosed with CM1 and treated by posterior fossa decompression. Patients who failed to respond to surgery were evaluated by CINE MR flow studies to assess presence of CSF flow at the foramen magnum and then by lumbar puncture if flow was present. The diagnosis of Chiari PTC was defined by recurrence of Chiari-like symptoms after decompression, elevated lumbar CSF pressure in the absence of ventriculomegaly, and transient resolution of symptoms with large volume lumbar CSF drainage.

RESULTS: Thirty-six of 192 patients did not improve with surgical decompression. Fifteen of 36 operative CM1 patients (41.6%) were found to have Chiari PTC. The most frequent symptoms of CM1/PTC patients were head pain, body aches, and balance difficulties. Three patients also experienced visual complaints. The mean maximum lumbar CSF pressure documented in this cohort was 26 cm of water in adults and 25.3 in children. All patients received treatment for the CM1/PTC that culminated with CSF shunt placement in 14/15. Seven of 9 pediatric patients had significant symptom resolution while 6/6 adult patients remained variably symptomatic.

CONCLUSION: CM1 and PTC co-exist in a surprising percentage of failed operative CM1 patients and present with a syndrome that is difficult to treat. The etiology of this association after Chiari decompression is unclear, though perhaps posterior fossa surgery in the setting of abnormal anatomy and potentially anomalous CSF flow dynamics contributes to CSF malabsorption and resultant or coexistant PTC.

Spontaneous CSF Rhinorrhoea-A Rare Complication of Pseudotumor Cerebri (http://medind.nic.in/jab/t06/i3/jabt06i3p144.pdf)

Another abstract only, however, I'd love to see the full text!

Association of the Adult Chiari Malformation and Idiopathic Intracranial Hypertension: more than a coincidence. (http://www.ncbi.nlm.nih.gov/pubmed/12699714)
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA. bejjanigk@msx.upmc.edu

There are significant similarities between the Adult Chiari Malformation (ACM) and Idiopathic Intracranial Hypertension (IIH). They include similar demographics, clinical presentation, and response to treatment. There is an eightfold increase in the incidence of significant tonsillar herniation in patients with IIH. Based on these findings and our observation in a subgroup of patients with failed ACM decompression, we suggest that these disorders are interrelated in a group of patients. The physiopathology is that of craniocephalic disproportion, i.e., a disproportion between the skull and the brain, due to a small skull or posterior fossa (like in ACM) and/or an engorged brain (like in IIH). This will occasionally lead to tonsillar ectopia. The craniocephalic disproportion will alter the brain compliance and lead to the symptomatology.

[mot]

A searchable data base with lots of great illustrations from a world famous neurosurgeon..
A lot of info about arachnoiditis, myelograms, laminectomies, CSF, surgery risks, etc.
http://www.burtonreport.com/

M

[LauraL840]

Persistent Cerebrospinal Fluid Leak: A Complication of the Combined Spinal-Epidural Technique (http://www.anesthesia-analgesia.org/cgi/content/full/98/3/828)

Persistent cerebrospinal fluid (CSF) leak is an apparently rare complication of dural puncture from spinal or epidural anesthesia. Combined spinal-epidural techniques are increasingly popular but persistent CSF leak has not been reported. We describe three parturients with persistent fluid leak from the insertion site after epidural catheter removal following combined spinal-epidural anesthesia. Uncertainties related to the diagnosis, treatment, and the implications of this complication are discussed, including ß2-transferrin immunofixation assay as a diagnostic test for the presence of CSF in this situation.

[Tamaretta]

Association between symptom duration and cerebrospinal fluid pressure, protein concentration, and number of cells in patients with intracranial hypotension.

http://www.ncbi.nlm.nih.gov/pubmed/19116838?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

[LauraL840]

I sure would like to read the entire article! And know what intravenous osmotic agent they used to treat!

Monitoring rebound intracranial hypertension by cine MRI after treatment of spontaneous intracranial hypotension in a patient with notable subdural hemorrhage (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7583-4TK2PHT-2&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=9e47101e1c65dd47e153659598d99b78)

Available online 1 October 2008.

Abstract

A 44-year-old man with spontaneous intracranial hypotension complicated by progressive subdural hematoma (SDH) had repeat bleeding during a headache-resolving period. After he underwent epidural blood patching (EBP), rebound intracranial hypertension occurred and was successfully treated with an intravenous osmotic agent. With cine magnetic resonance imaging, we were able to examine the flow dynamics of the cerebrospinal fluid, to verify rebound intracranial hypertension after EBP, and to non-invasively confirm the effectiveness of treatment. Among patients with spontaneous intracranial hypotension complicated with clinically significant SDH, pseudo-normalization of intracranial pressure suggests the presence of acute rebound intracranial hypertension after EBP.

[LauraL840]

From Dr. Wharen @ Mayo Jax, FLA. A 2009 Article (full text):

Trigeminal Neuralgia in a Patient With Spontaneous Intracranial Hypotension (http://www.fpa-support.org/learning/Articles/2009/documents/CheshireTNwintrcranialhypotension4.9.09.pdf)

Abstract as follows: "Spontaneous intracranial hypotension and trigeminal neuralgia are examples of pain syndromes arising from shifting anatomical relationships in the posterior fossa. We report both conditions occurring in the same patient and resolving following surgical closure of a cervical nerve root sleeve dural defect. This case further elucidates the pathophysiologic basis of both forms of head pain."

[LauraL840]

Now here's something slightly different ... a blog from ANJR (American Journal of Neuroradiology)! There are a couple entries regarding intracranial hypotension. This is a relatively new (January 2009 start date) blog which is directly tied to ANJR. I don't recall ever having seen an open-access blog tied to a medical journal before.

If you're interested, you can check it out here: ANJR Blog (http://www.ajnrblog.org/)

[LauraL840]

Internet Trolls (http://www.flayme.com/troll/).... apparently they do exist, who knew? :)

[mot]

For those who want to be expert google people:

http://techtracer.com/2008/01/06/10-most-amazing-google-search-tricks/

[mot]

All about so called money makers, players, and landmines of internet forums.
This 5 part series is very informative.

http://www.selfhelpmagazine.com/articles/internet/problemposters1.html


M:)

[LeakyLaurainwv]

Found this article on EbscoHost

It is a really good article if you have the ability to get it full text:
In this study, only 29 out of 55 patients got relief from the EBP.
The group over 40 were more likely to get relief. This group was more likely to have a cervicothoracic CSF leak.

http://www3.interscience.wiley.com/journal/118817106/abstract?CRETRY=1&SRETRY=0

[LauraL840]

Found this article on EbscoHost

It is a really good article if you have the ability to get it full text:
In this study, only 29 out of 55 patients got relief from the EBP.
The group over 40 were more likely to get relief. This group was more likely to have a cervicothoracic CSF leak.

http://www3.interscience.wiley.com/journal/118817106/abstract?CRETRY=1&SRETRY=0


Can you include the title? I tried the link, but get a browser error, probably security on my end but I can't anything.

[LeakyLaurainwv]

The link worked for me the first time, but I get a user error now. Sigh!!!
Anyway, the title is Treatment Outcomes in Spontaneous Intracranial Hypotension: Do Epidural Blood Patches Stop the Leaks? If you google the title, you can find the abstract. I have a full text article, but I found it on EbscoHost. You could probably request a reprint from the author. The author of the study is Dr. James H. Diaz from Louisiana State University Health Sciences Center in New Orleans.

For those of you out there that wanted a study that doesn't report that everyone gets better with interventions, this one suggested that the intervention failed to offer relief of headache in 29/55 patients.

Good luck finding it and happy reading.

LeakyLaura

[LauraL840]

Thanks Laura,

I just emailed the author, that usually gets me the fastest results!

[LeakyLaurainwv]

Another Ebscohost article.

Clinical features and Outcomes in Spontaneous Intracranial hypotension: a survey of 90 consecutive patients.

The abstract is on line, but I sure would like to read the full text.

I'll try to add a link, but it never works for me.

www.citeulike.org/article/4495828

[LauraL840]

The link worked! :D

One of the authors is Dr. Angelo Franzini (http://www.angelofranzini.com/), the Italian that uses blood/fibrin mix and recently published an AWESOME article that bstone posted text! You might try to PM 'bstone' and see if he can get a full text of this one as he has access to them.

[bstone]

The link worked! :D

One of the authors is Dr. Angelo Franzini (http://www.angelofranzini.com/), the Italian that uses blood/fibrin mix and recently published an AWESOME article that bstone posted text! You might try to PM 'bstone' and see if he can get a full text of this one as he has access to them.

Usually all I need is the name of the article. It's somewhat helpful to know when and which journal it was in, as well.

[LauraL840]

Published 18 February 2009
A 16-year-old boy presented with a 4-week history of sudden onset and progressively worsening occipital headache. Symptoms were exacerbated on sitting and standing, and initially alleviated with recumbency and on extensive neck flexion. There was no medical or familial history. He was a keen line skater, regularly executing back flips on a skating ramp. However, there was no history of trauma sustained preceding the onset of headache. On admission, neurological, fundus and general examinations were normal.

For more information, read here:
Spontaneous intracranial hypotension in adolescence (http://casereports.bmj.com/cgi/content/full/2009/feb16_1/bcr2006096644)

[LauraL840]

There are a couple people who have seen the doctor who wrote this article; Dr. Robert Wharen @ Mayo Jacksonville, FLA. This was published in 2009.

Trigeminal Neuralgia in a Patient With Spontaneous Intracranial Hypotension (http://www.fpa-support.org/learning/Articles/2009/documents/CheshireTNwintrcranialhypotension4.9.09.pdf)

Spontaneous intracranial hypotension and trigeminal neuralgia are examples of pain syndromes arising from shifting
anatomical relationships in the posterior fossa.We report both conditions occurring in the same patient and resolving following
surgical closure of a cervical nerve root sleeve dural defect. This case further elucidates the pathophysiologic basis of both forms
of head pain.