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Ali Alaraj, Troy Munson, Sebastian R. Herrera, Victor Aletich, Fady T. Charbel and Sepideh Amin-Hanjani

S evere CSF hypovolemia, or “brain sag” phenomenon, has only recently been described and is seen most commonly in patients with aneurysmal SAH after craniotomy for aneurysm clipping along with presurgical placement of a lumbar drain. 1 , 6 , 7 , 10 Symptoms include a sudden deterioration in mental status with signs of transtentorial herniation, such as pupillary dilation or asymmetry, and extensor posturing despite a low measured ICP. Patients typically show rapid improvement after placement in the Trendelenburg position. The differential diagnosis of

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E. Sander Connolly Jr.

Alaraj and colleagues 1 report on 5 patients who, following the surgical repair of ruptured anterior communicating artery (ACoA) aneurysms aided by spinal drainage with or without fenestration of the lamina terminalis, demonstrated clinical “brain sag” with classic CT features: elongation of the midbrain and effacement of the basal cisterns. In all cases the angiogram obtained during the “sag episode” showed inferior displacement of the basilar artery when compared with the “pre-sag” angiogram, and in 3 cases, this displacement was so severe that the

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Wouter I. Schievink, Miriam Nuño, Todd D. Rozen, M. Marcel Maya, Adam N. Mamelak, John Carmichael and Vivien S. Bonert

), also were excluded. For patients who were found to have hyperprolactinemia, prolactin levels also were measured following treatment of their spontaneous intracranial hypotension. Results of brain MRI studies were scored by a boardcertified neuroradiologist (M.M.M.) who was blinded to the results of pituitary hormone measurements. One or more of the following imaging findings were considered as brain sagging: downward displacement and distortion of midbrain and pons, flattening of the ventral surface of pons, inferior displacement of the mammillary bodies, downward

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Wouter I. Schievink and James Tourje

displacement of the brain. Note the obliteration of the suprachiasmatic cistern and flattening of the pons. Examination The patient's neurological examination was significant for the finding of a left foot drop. The lumbar incision had healed well without any palpable fluid collection. On review of the patient's MR image, clear evidence of brain sagging was found ( Fig. 1 ). A repeated MR image obtained 10 days after the initial one showed complete resolution of the left-sided subdural fluid collection; however, a very similar subdural fluid collection was observed to have

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Wouter I. Schievink, David Palestrant, M. Marcel Maya and George Rappard

to the operating room. F ig . 2. Axial CT scans showing obliteration of subarachnoid cisterns and the right frontal extracerebral hematoma due to brain sagging (A–C) with resolution after surgical repair of a spinal CSF leak (D–F). Pseudosubarachnoid hemorrhage due to intracranial hypotension is shown in panel A, and a right frontoparietal cerebral infarction is shown in panels C–F. Second Operation A right craniotomy was performed and the epidural hematoma was evacuated. The dura mater was opened, but no subdural hemorrhage was found. The brain was

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John L. D. Atkinson, Brian G. Weinshenker, Gary M. Miller, David G. Piepgras and Bahram Mokri

worsening of his headaches in any erect posture and progressively severe nausea and vomiting, singultus, dizziness, and bowel and bladder incontinence. Examination Neurological examination revealed symmetrical hyperreflexia, but the results were otherwise normal. Magnetic resonance imaging revealed diffuse dural enhancement, significant brain sagging with loss of CSF cisterns, marked brainstem distortion, tonsillar descent with impaction at C-2, and a barely discernible cerebellomedullary fissure. Thin-slice CT myelography revealed a left L-2 meningeal

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Enrico Ferrante and Giuseppe Pontrelli

headache due to intracranial hypotension (5 cm H 2 O). Orthostatic headache was associated with a CSF leak from the thigh after pathological fractures of the femur and pelvis. The chronic CSF leak led to acquired Chiari malformation (CM). After an epidural blood patch (EBP) the CSF leak resolved, the CM disappeared, and her neurological status improved. In the paper, the authors affirm that the association between the CSF leak and CM can be explained as follows. GSD led to the development of the chronic low-grade CSF leak. The CSF leak led to brain sag, including

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Neeraj Kumar, Newton B. Neidert, Felix E. Diehn, Norbert G. Campeau, Jonathan M. Morris and Haraldur Bjarnason

differential causes CSF runoff from the thecal sac to the IVC. Right: Following stenting there is normalization of pressure in the IVC segment. This results in a lack of pressure gradient, which renders the SCVF nonfunctional. The following day, the patient underwent an IVC and bilateral iliac vein recanalization and stenting procedure, which was followed over a few days by prompt and complete resolution of all symptoms. A brain and spine MRI study done 15 weeks later showed resolution of the brain sag, cervical syrinx, and pial vascularity ( Fig. 1 ). A Doppler ultrasound

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Pranshu Sharma, Aseem Sharma and Ari G. Chacko

CSF on both sequences and was especially observable on STIR images because the bright intensity of the fluid contrasted sharply with the dark signal from muscles and fat. Initial Treatment Because of the patient's history of postural headaches and the imaging features of brain sagging and fluid collection in epidural and extraspinal space, the diagnosis of tonsillar herniation with syrinx formation caused by spontaneous spinal CSF leakage and chronic intracranial hypotension was considered. The patient was maintained on conservative treatment for the next 2

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Wouter I. Schievink and M. Marcel Maya

immediately after an uneventful diagnostic lumbar puncture performed for the evaluation of a new-onset nonpositional biparietal headache associated with nausea and fever. Examination of the CSF had shown no abnormality. The patient's headaches had persisted in spite of bed rest and 4 lumbar epidural blood patches. The results of neurological examination were normal. The results of an MRI examination of the brain prior to the lumbar puncture were normal, but MRI following the lumbar puncture showed brain sagging and pachymeningeal enhancement. An MRI examination of the spine