Search Results (61)

Background/Objectives: Spontaneous intracranial hypotension (SIH) is a rare pathology that arises in the context of a known or suspected cerebral spinal fluid (CSF) leak. A key symptom of SIH is an orthostatic headache; however, additional neurological complications are common. This case study not only highlights the co-existence of Menière’s disease and SIH but describes a subsequent complication of benign paroxysmal positional vertigo (BPPV) and management thereof. Case Description: The patient is a 61-year-old female who presented to the emergency department due to an intractable headache, right sided weakness and aphasia. CT/MRI revealed a subdural hematoma overlying the left cerebral hemisphere measuring up to 8 mm with 4 mm left to right midline shift. Fluoro-guided total spine myelogram, cisternogram, and lumbar epidural blood patch were performed for suspected SIH. As headache, right sided weakness and aphasia resolved, the patient began reporting onset of constant “spinning” dizziness, tinnitus and aural fullness mimicking symptoms of a Menière’s attack. The vestibular examination was consistent with compensated bilateral Menière’s disease (left > right) and right horizontal canalithiasis BPPV. The patient was treated with Gufoni and Lempert maneuvers with complete resolution of positional dizziness and associated nystagmus along with improved balance and gait. Discussion/Conclusions: This case study highlights the importance of multidisciplinary assessment in complex neurological cases and specifically recommends that patients with Menière’s disease accompanied by intractable headaches undergo extended neuroradiological examination of the brain to exclude underlying spontaneous intracranial hypotension syndrome. Full article

Background/Objectives: Intracranial hypotension is a rare and underdiagnosed serious condition characterized by low cerebrospinal fluid (CSF) pressure, often resulting from trauma to the dura mater. While manual therapy is increasingly used for musculoskeletal complaints, it is not without risk and may, in rare cases, result in complications such as dural tears. Although these complications are rare, they require early recognition and appropriate treatment to prevent further morbidity. This case report aims to highlight a rare presentation of multilevel dural defects in temporal association with manual therapy and to demonstrate the efficacy of epidural blood patch (EBP) treatment. Case Presentation: We report a case of a 46-year-old woman without chronic illness who developed worsening orthostatic headaches, weakness, and vomiting after multiple manual therapy sessions. Only after 6 months did the patient undergo magnetic resonance imaging (MRI), which revealed intracranial hypotension due to dural damage in the spinal dura mater at C6–T1 and T8–T10, brain sagging, and an increased risk of subdural hematoma. After excluding other causes of dural defects, EBP was performed under CT guidance at C6–C7 and T8–T9, which resulted in symptom regression. Follow-up MRI was recommended for the patient. Conclusions: This case highlights a rare but clinically significant occurrence of multilevel dural defects and intracranial hypotension in temporal association with manual therapy. This emphasizes the critical role of timely diagnosis using MRI and the clinical effectiveness of EBP as a minimally invasive procedure. Full article

MaChiP 1.0 used static magnetic resonance imaging (MRI) to identify coexistent idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH) in Chiari I malformation (CM-I), improving etiologic characterization. This Protocol/Perspective paper presents MaChiP 2.0 as a testable, artificial intelligence (AI)-integrated imaging roadmap for acquired Chiari I malformation (CM-I), intended to support the differentiation between congenital and acquired tonsillar descent and to guide leak-localization imaging in suspected spontaneous intracranial hypotension (SIH). Building on the structural foundation of MaChiP 1.0, this framework outlines how dynamic craniospinal imaging tools, including phase-contrast magnetic resonance imaging (PC-MRI) and displacement encoding with stimulated echoes (DENSE), may be combined with conventional morphologic markers to refine imaging evaluation. It further describes the potential use of currently available artificial intelligence (AI) methods for segmentation, cerebrospinal fluid (CSF) flow quantification, and imaging biomarker assessment. Noninvasive magnetic resonance (MR)-based techniques are proposed as first-line approaches for leak detection, while digital subtraction myelography (DSM) and computed tomography myelography (CTM) remain the reference standards when initial imaging is inconclusive. Full article

Background: Robot-assisted laparoscopic radical prostatectomy (RALP) requires prolonged steep Trendelenburg positioning, which increases intraocular and intracranial pressure. Although transient visual field defects have been documented after RALP using objective perimetric testing, data on patient-reported visual outcomes remain limited. We hypothesized that intraoperative optic nerve sheath diameter (ONSD) measurements and hemodynamic variables would be associated with postoperative patient-reported visual symptoms. Methods: This prospective, single-center observational cohort study enrolled consecutive adult patients undergoing RALP between March and September 2023 at Ospedale Santo Stefano, Prato, Italy. Patients with pre-existing glaucoma, ocular disease, or intracranial hypertension were excluded. Intraoperative ONSD was measured by transorbital ultrasound at three time points: before Trendelenburg (t1), 30 min after Trendelenburg (t2), and at end of Trendelenburg (t3). Postoperative visual symptoms were assessed at ≥1 month follow-up using the validated Catquest-9SF questionnaire. Rasch analysis converted ordinal responses to interval-level measures. Logistic regression explored associations between visual complaints and intraoperative predictors (Rasch scores, lowest mean arterial pressure [MAP], maximum ONSD). Results: Fifty-five patients were enrolled. Six patients (10.9%) reported new subjective visual symptoms at follow-up. Rasch-transformed scores were associated with the presence of these symptoms (coefficient 1.38; p < 0.05). Lowest intraoperative MAP (p = 0.081) and maximum ONSD (p = 0.811) did not reach statistical significance as independent factors. Conclusions: Patient-reported visual symptoms occurred in approximately 11% of patients after RALP. Postoperative Rasch-transformed visual function scores correlated with these complaints. While intraoperative ONSD was not associated with visual outcomes, the potential role of intraoperative hypotension requires further investigation in larger, powered cohorts. Full article

Duropathies represent a spectrum of disorders associated with spinal dural tears and cerebrospinal fluid (CSF) leaks. Diagnosis and treatment is often complicated by overlapping clinical manifestations. This review aims to synthesize current literature on duropathies, focusing on their clinical, neuroradiological, and pathophysiological features. A comprehensive literature review was conducted, analyzing various conditions classified as duropathies, including spontaneous intracranial hypotension (SIH), superficial siderosis (SS), spinal cord herniation, and, as added issue, arachnoid webs. The review emphasized the importance of imaging techniques such as MRI and CT myelography in diagnosing these conditions. Duropathies can arise from congenital anomalies, trauma, and degenerative changes, with SIH being characterized by orthostatic headaches and neurological deficits. Imaging typically reveals specific patterns, such as a widened dorsal subarachnoid space and ventral displacement of the spinal cord. Syringomyelia was frequently associated with arachnoid webs, and complications like SS and bibrachial amyotrophy were noted in patients with persistent ventral spinal CSF leaks. The unifying concept of duropathies is proposed, emphasizing the need for timely intervention to mitigate long-term neurological consequences. Enhanced diagnostic strategies are crucial for improving patient outcomes, and a multidisciplinary approach is recommended for the management of these complex disorders. Further research is warranted to clarify the pathophysiological mechanisms underlying duropathies and to establish standardized treatment protocols. Full article

Background: Maintaining an adequate mean arterial pressure (MAP) and cerebral perfusion pressure to ensure proper perfusion and oxygen delivery to all major organs is crucial—especially for neurosurgical patients after subarachnoid hemorrhage or traumatic brain injury—for preventing secondary brain damage or delayed cerebral ischemia. Currently, most neurosurgical intensive care units rely on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) values to guide therapy. Fluid resuscitation and norepinephrine are standard treatments for achieving a CPP between 60 and 70 mmHg; however, patients sometimes experience norepinephrine-refractory hypotension. In such cases, vasopressin is often the preferred medication; it is widely utilized and has gained interest in treating septic shock or refractory hypotension following cardiac surgery or hypovolemic shock. Recent studies have also shown the significant impact of vasopressin on resuscitation after traumatic brain injury (TBI) and its effect on CPP during ICU care. Nevertheless, little is known about how vasopressin affects cerebral perfusion and oxygenation, especially in patients with subarachnoid hemorrhage. Methods: This preliminary retrospective single-arm study examined how vasopressin affects P_btO₂ and cerebral blood flow using the non-invasive QuantixND^® device. After administering vasopressin for treating catecholamine-refractory hypotension, MAP, CPP, ICP, P_btO₂, and cerebral blood flow were measured over a 20-min period. Results: In this small cohort, vasopressin sufficiently improved MAP and CPP over a 20 min period following AVP bolus administration with a slight decline at later time points. The ICP decreased throughout this period, indicating some level of autoregulation. In contrast, cerebral blood flow did not improve despite the rise in CPP, and P_btO₂ levels remained below 20 mmHg. Conclusions: We conclude that vasopressin could be a viable option for maintaining MAP and CPP, but caution should be exercised in patients with already impaired cerebral perfusion. Furthermore, relying solely on CPP as the therapeutic guide in subarachnoid hemorrhage patients appears to be at least questionable. Full article

Background: Severe traumatic brain injury (TBI) often leads to elevated intracranial pressure (ICP) that requires aggressive management. Inducing burst suppression with deep sedation is an established therapy for refractory intracranial hypertension. Traditionally, barbiturate coma has been used to achieve burst-suppression EEG in TBI patients, but alternative sedative agents (propofol, midazolam, ketamine, dexmedetomidine) are increasingly utilized in modern neurocritical care. This review compares barbiturates with these alternatives for inducing burst suppression in adult TBI, focusing on protocols, mechanisms, efficacy in controlling ICP, safety profiles, and impacts on neurological outcomes. Methods: A search of the literature was performed, including clinical trials, observational studies, and guidelines on deep sedation for ICP control in adult TBI. Studies comparing high-dose barbiturates to other sedatives (propofol, midazolam, ketamine, dexmedetomidine) in the context of burst suppression or severe TBI management were included. Data on sedative protocols (dosing and EEG targets), mechanisms of action, ICP-lowering efficacy, complications, and patient outcomes were extracted and analyzed qualitatively. Results: High-dose barbiturates (e.g., pentobarbital or thiopental) and propofol are both effective at inducing burst-suppression EEG and reducing ICP via cerebral metabolic suppression. Barbiturate coma remains a third-tier intervention reserved for ICP refractory to other treatments. Propofol infusion has become first-line for routine ICP control due to rapid titratability and shorter half-life, though it can also achieve burst suppression at high doses. Midazolam infusions provide sedation and seizure prophylaxis but yield less metabolic suppression and ICP reduction compared to barbiturates or propofol, and are associated with longer ventilation duration and delirium. Ketamine, once avoided for fear of raising ICP, has shown neutral or lowering effects on ICP when used in ventilated TBI patients, thanks to its analgesic properties and maintenance of blood pressure; however, ketamine alone does not reliably produce burst-suppression patterns. Dexmedetomidine offers sedative and anti-delirium benefits with minimal respiratory depression, but it is generally insufficient for deep burst-suppressive sedation and has only a modest effect on ICP. In comparative clinical evidence, propofol and barbiturates both effectively lower ICP, but neither has demonstrated clear improvement in long-term neurological outcome when used prophylactically. Early routine use of barbiturate coma may increase complications (hypotension, immunosuppression), and thus, current practice restricts it to refractory cases. Modern sedation protocols emphasize using the minimal necessary sedation to maintain ICP < 22 mmHg, with continuous EEG monitoring to titrate therapy to a burst-suppression target (commonly 2–5 bursts per minute) when deep coma is employed. Conclusions: In adult TBI patients with intracranial hypertension, propofol-based sedation is favored for first-line ICP control and can achieve burst suppression if needed, whereas high-dose barbiturates are reserved for ICP crises unresponsive to standard measures. Compared to barbiturates, alternative agents (propofol, midazolam, ketamine, dexmedetomidine) offer differing advantages: propofol provides potent, fast-acting metabolic suppression; midazolam adds anticonvulsant sedation for prolonged use at the cost of slower wake-up; ketamine supports hemodynamics and analgesia; dexmedetomidine aids lighter sedation and delirium control. The choice of agent is guided by the clinical scenario, balancing ICP reduction needs against side effect profiles. While all sedatives can transiently reduce ICP, careful monitoring and a tiered therapy approach are essential, as no sedative has conclusively improved long-term neurological outcomes in TBI. EEG monitoring for burst suppression and meticulous titration is required when employing barbiturate or propofol coma. Ongoing research into optimal combinations and protocols may further refine sedation strategies to improve safety and outcomes in severe TBI. Full article

Duropathies encompass a spectrum of disorders linked to spinal dural tears and cerebrospinal fluid (CSF) leaks, resulting in significant neurological manifestations. This review synthesizes the current literature on duropathies, focusing on their anatomical and pathophysiological aspects, including conditions such as superficial siderosis, spontaneous intracranial hypotension, and spinal cord herniation. The methodologies employed include comprehensive evaluations through neuroimaging techniques such as MRI and CT myelography, alongside clinical assessments of symptoms like ataxia, hearing loss, and cognitive impairment. Key findings highlight the prevalence of dural defects in patients with superficial siderosis and the association of persistent CSF leaks with various neurological impairments. The review emphasizes the need for a standardized diagnostic and therapeutic approach to enhance patient management and improve outcomes. By addressing the interrelated nature of these conditions, the study underscores the importance of early intervention to mitigate long-term neurological consequences. Overall, the findings advocate for further research to elucidate the mechanisms underlying duropathies and the development of effective treatment strategies, ultimately aiming to improve the quality of life for affected individuals. Full article

Background and Clinical Significance: Spontaneous intracranial hypotension (SIH) is a rare cause of headache characterised by cerebrospinal fluid (CSF) leakage, with an estimated incidence of 3.7 to 5 cases per 100,000 per year, peaking around the age of 40 years. Its diagnosis and management are particularly challenging in pregnancy due to overlapping symptoms and limited diagnostic options. Case Presentation: We report the case of a 42-year-old pregnant woman at 14 weeks of gestation presenting with a history of orthostatic headache and facial sinus tenderness, later diagnosed as spontaneous intracranial hypotension. Conclusions: Headache is a common clinical symptom that may be associated with a wide spectrum of underlying conditions, ranging from benign causes such as migraine or tension-type headache to potentially life-threatening pathologies, including subarachnoid haemorrhage. This case illustrates the diagnostic complexity of SIH in pregnancy and the importance of a multidisciplinary approach and vigilance for neurological symptoms during pregnancy. Full article

Background: Cerebrospinal fluid (CSF) shunting remains a crucial intervention in the treatment of paediatric hydrocephalus. Overdrainage syndrome is a well-recognised but potentially severe complication, in which hyperostosis cranii ex vacuo—diffuse thickening of the cranial bones—emerges as an adaptive response to chronic intracranial hypotension. Currently, no established diagnostic criteria exist to reliably identify and classify this phenomenon, nor are there defined strategies to prevent associated complications of reduced intracranial compliance. Objective: This study aimed to characterise the morphoradiological and clinical phenotype of hyperostosis cranii ex vacuo in paediatric patients with long-term shunt dependency and to propose its classification as a fifth subtype of CSF overdrainage syndrome with direct implications for long-term neurosurgical care. Methods: A retrospective observational study was conducted on nine paediatric patients with radiologically confirmed diffuse calvarial thickening secondary to surgical treatment of hydrocephalus. Quantitative morphometric analysis of frontal, parietal, and occipital bones, sella turcica dimensions, and dural enhancement was performed using high-resolution neuroimaging. Clinical records were reviewed for hydrocephalus aetiology, shunt revision history, and neurological impairment. Results: All patients exhibited a mean two-fold increase in age-adjusted calvarial thickness. Premature craniosynostosis was identified in 33.3% of cases. Diffuse pachymeningeal enhancement was noted in all patients with contrast-enhanced imaging. Neurological comorbidities included epilepsy, spastic paraparesis, and features of Chiari type I malformation. Conclusions: Hyperostosis cranii ex vacuo represents a distinct and underrecognised consequence of chronic CSF overdrainage. We propose preliminary diagnostic criteria and a structured management pathway—from radiological recognition through ICP assessment to tiered surgical intervention. Formal recognition of this entity as a fifth subtype of CSF overdrainage syndrome may enhance early diagnosis, improve risk stratification, and guide long-term surveillance of shunted children. Full article

Background/Objectives: Spontaneous intracranial hypotension (SIH), caused by spinal cerebrospinal fluid (CSF) leakage, commonly presents with orthostatic headache and CSF hypovolemia. While CSF dynamics in the cerebral aqueduct are well studied, alterations in spinal CSF flow remain less defined. We aimed to quantitatively assess spinal CSF flow at C2 using phase-contrast (PC) MRI enhanced by artificial intelligence (AI) and to evaluate its utility for diagnosing SIH and predicting responses to epidural blood patch (EBP). Methods: We enrolled 31 patients with MRI-confirmed SIH and 26 age- and sex-matched healthy volunteers (HVs). All participants underwent ECG-gated cine PC-MRI at the C2 level and whole-spine MR myelography. AI-based segmentation using YOLOv4 and a pulsatility-based algorithm was used to extract quantitative CSF flow metrics. Between-group comparisons were analyzed using Mann–Whitney U tests, and receiver operating characteristic (ROC) analysis was used to evaluate diagnostic and predictive performance. Results: Compared to HVs, SIH patients showed significantly reduced CSF flow parameters across all metrics, including upward/downward mean flow, peak flow, total flow per cycle, and absolute stroke volume (all p < 0.001). ROC analysis revealed excellent diagnostic accuracy for multiple parameters, particularly downward peak flow (AUC = 0.844) and summation of peak flow (AUC = 0.841). Importantly, baseline CSF flow metrics significantly distinguished patients who required one versus multiple epidural blood patches (EBPs) (all p < 0.001). ROC analysis demonstrated that several parameters achieved near-perfect to perfect accuracy in predicting EBP success, with AUCs up to 1.0 and 100% sensitivity/specificity. Conclusions: AI-enhanced PC-MRI enables the robust, quantitative evaluation of spinal CSF dynamics in SIH. These flow metrics not only differentiate SIH patients from healthy individuals but also predict response to EBP treatment with high accuracy. Quantitative CSF flow analysis may support both diagnosis and personalized treatment planning in SIH. Full article

The current management of severe traumatic brain injury (TBI) focuses on maintaining cerebral perfusion pressure (CPP) to prevent or minimize secondary brain injury, limit cerebral edema, optimize oxygen delivery to the brain, and reduce primary neuronal damage by addressing contributing risk factors such as hypotension and hypoxia. Hypotension and cardiac dysfunction are common in patients with severe TBI, often requiring treatment with intravenous fluids and vasopressors. The primary categories of resuscitation fluids include crystalloids, colloids (such as albumin), and blood products. Fluid osmolarity is a critical consideration in TBI patients, as hypotonic fluids, such as balanced crystalloids, may increase the risk of cerebral edema development and worsening. Hyperosmolar therapy is a common therapeutic approach in patients with intracranial hypertension; however, its use as a resuscitation fluid is not associated with benefits in patients with TBI and is not recommended. Given the contradictory results of trials on blood transfusion strategies in patients with TBI, the transfusion approach should be tailored to individual systemic and cerebral physiological parameters. The evaluation of recent randomized clinical trials will provide insight into whether a liberal or restrictive transfusion strategy is preferred for this patient population. Hemodynamic and multimodal neurological monitoring to assess cerebral oxygenation, autoregulation, and metabolism are essential tools for detecting early hemodynamic alterations and cerebral injury, guiding resuscitation management, and contributing to improved outcomes. Full article

In this study, pharmacotherapies of abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) in animal studies were reviewed from the perspective of ACS/IAH as failed cytoprotection issues, as non-specific injuries, and from the point of view of the cytoprotection concept as resolution. Therefore, this review challenges the unresolved theoretical and practical issues of severe multiorgan failure, acknowledged significance in clinics, and resolving outcomes (i.e., open abdomen). Generally, the reported agents not aligned with cytoprotection align with current pharmacotherapy limitations and have (non-)confirmed effectiveness, mostly in only one organ, mild/moderate IAH, prophylactic application, and provide only a tentative resolution. Contrarily, stable gastric pentadecapeptide BPC 157 therapy, as a novel and relevant cytoprotective mediator having pleiotropic beneficial effects, simultaneously resolves many targets, resolving established disturbances, specifically compression/ischemia (grade III and grade IV), and decompression/advanced reperfusion. BPC 157 therapy rapidly activates collateral bypassing pathways, and, in ACS and IAH, and later, in reperfusion, there is a “bypassing key” (i.e., azygos vein direct blood flow delivery). This serves to counteract multiorgan and vessel failure, including lesions and hemorrhages in the brain, heart, lung, liver, kidney and gastrointestinal tract, thrombosis, peripherally and centrally, intracranial (superior sagittal sinus), portal and caval hypertension and aortal hypotension, occlusion/occlusion-like syndrome, advanced Virchow triad circumstances, and free radical formation acting as a membrane stabilizer and free radical scavenger. Likewise, not only in ACS/IAH resolving, but also in other occlusion/occlusion-like syndromes, this “bypassing key” could be an effect of the essential endothelial cytoprotective capacity of BPC 157 and a particular modulatory effect on the NO-system, and a rescuing impact on vasomotor tone. Full article

Background and Objectives: End-stage renal failure (ESRF) patients are at an increased risk of various neurological complications, particularly after hemodialysis. The current case report describes a rare presentation of spontaneous intracranial hypotension (SIH) in a patient with ESRF caused by systemic lupus erythematosus (SLE). Methods: We present our case report. We also performed a systematic literature search in PubMed, Scopus, and Dimensions for the current literature review. Results: A total of 296 unique articles were identified, and their full text was retrieved. However, only one case report was relevant to our study and is summarized thereunder. The treatment approach involved high-dose intravenous steroids, surgical evacuation of the cranial subdural collections, and epidural blood patches to seal the presumed dural defect. Conclusions: This case report describes a rare presentation of SIH in a young patient with ESRF due to SLE. Diagnostic imaging revealed extensive subdural and epidural fluid collections in the brain and spinal cord, respectively, along with a few T2 FLAIR hyperintensities noted in the right thalamus, left cerebellar hemisphere, and right occipital gyrus that subsequently resolved. The treatment approach involved high-dose intravenous steroids, surgical evacuation of the cranial subdural collections, and epidural blood patches to seal the presumed dural defect. Full article

Background and Clinical Significance: Symptoms of spontaneous intracranial hypotension include orthostatic headaches due to decreased cerebrospinal fluid (CSF) levels. Here, we present a 24-year-old female admitted to an obstetrics and gynecology department with primary complaints of lower abdominal pain and dysmenorrhea with subsequent diagnosis of spontaneous intracranial hypotension (SIH). Case Presentation: The patient had experienced nausea and lower abdominal pain independent of her menstrual cycle 5 days before admission, for which she visited the emergency department 3 days later. On admission, her symptoms were temporarily relieved by administering analgesics; thus, she was discharged. However, later, the symptoms worsened. Consequently, she returned to the emergency department for further evaluation, including blood tests, imaging, and endoscopy, which revealed no nausea- or abdominal pain-related organic abnormalities. On day 10, she developed a headache, aggravated by lying in the supine position and improved by sitting. Additional history revealed a diagnosis of SIH owing to the worsening abdominal pain in the supine position. An ¹¹¹In CSF cavity scintigram showed no spinal fluid leakage; early intrabladder radioisotope (RI) accumulation was observed, and the residual 24 h CSF cavity RI was >30%. At a referral specialist hospital, an epidural saline infusion test was performed, which improved her headache and lower abdominal pain. Blood patch therapy improved her lower abdominal pain, headache, and dysmenorrhea. Conclusions: The final diagnosis was SIH, with symptoms attributed to CSF depletion. The patient also experienced rare paradoxical postural-related headaches and lower abdominal pain, aggravated by lying in the supine position, contributing to the final diagnosis. Full article