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Carter E. Beck, Norman W. Rizk, Lydia T. Kiger, David Spencer, Laureen Hill, and John R. Adler

M ost patients with intracranial hypotension present with clinically mild symptoms, such as postural headache, that resolve spontaneously in only a few days. 1 In its mildest form, intracranial hypotension is a common disorder that occurs following the performance of a significant proportion of procedures such as lumbar puncture and myelography. It may also complicate ventriculoperitoneal shunt placement in the so-called “overshunting syndrome.” A growing literature provides description of a more severe syndrome whose manifestations include postural headache

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Hamad I. Farhat, Brian Hood, Steven Vanni, and Allan D. Levi

S pontaneous intracranial hypotension results in CSF leakage from a breach in the dural sac, with most leaks identified in the thoracic spine. 5 Other sources include skull base defects through the cribriform plate or via an encephalocele. Spinal etiologies include meningeal diverticula and ruptured meningeal cysts. The classic clinical presentation of a patient with SIH is orthostatic headache, that is, headache in the upright position, which is relieved by recumbency; 5 however, as the entity becomes better characterized, presenting symptoms can be

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Wouter I. Schievink, Ray M. Chu, M. Marcel Maya, J. Patrick Johnson, and Hart C. M. Cohen

S pontaneous intracranial hypotension has become a well-known cause of headache, and a wide variety of associated symptoms have been reported, including coma, dementia, and parkinsonism. 17 Rarely has spontaneous intracranial hypotension been associated with symptoms or signs referable to the spinal cord or spinal nerve roots. 1 , 4 , 8 , 9 , 16 , 19 , 22 We report our experience with cases of spinal manifestations of spontaneous intracranial hypotension to further elucidate the clinical spectrum of spontaneous intracranial hypotension. Methods Our

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

S pontaneous intracranial hypotension is an important cause of new, daily, persistent headaches that usually afflicts young to middle-aged adults, with a female predominance and a peak incidence in the 5th decade of life. 16 The headache is typically orthostatic and is often accompanied by nausea, neck pain, and hearing abnormalities. Spontaneous intracranial hypotension is uncommon, with an estimated incidence of approximately 5 per 100,000 per year. The cause of spontaneous intracranial hypotension is almost always a spontaneous spinal CSF leak, and a

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Vishnumurthy Shushrutha Hedna, Abhay Kumar, Bayard Miller, Sharathchandra Bidari, Arash Salardini, Michael F. Waters, Maria Hella, Edward Valenstein, and Stephan Eisenschenk

blood patch. The various brain imaging abnormalities described by other authors in the literature are helpful. 7 Careful interpretation of images is required as there are instances in which subdural fluid collection due to IH was misdiagnosed as a neurosurgical problem and was evacuated, resulting in bad outcome. Nonetheless, there are instances in which cerebellar descent due to IH has been misdiagnosed as Chairi malformation. Conclusions Intracranial hypotension may present with clinical and electrographic activity including mental status changes and

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Neurosurgical Forum: Letters to the Editor To The Editor Akira Matsumura , M.D., Ph.D. Izumi Anno , M.D., Ph.D. Tadao Nose , M.D., Ph.D. University of Tsukuba Ayataka Fujimoto , M.D. Yasushi Shibata , M.D., Ph.D. Masao Okazaki , M.D. Kitaibaraki Municipal Hospital Ibaraki, Japan 914 916 Abstract The authors present the case of a 55-year-old man suffering from intractable spontaneous intracranial hypotension, in whom

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Wouter I. Schievink and James Tourje

I ntracranial hypotension is a commonly encountered problem in neurosurgical practice. It is characterized by orthostatic headaches and may be due to lumbar puncture, postoperative or traumatic dural tears, or overdraining CSF shunts. 3, 6 Recently, several series of patients have been described as having spontaneous spinal CSF leaks and intracranial hypotension. 1, 3, 7 In cases of intracranial hypotension, MR imaging of the brain typically demonstrates diffuse pachymeningeal enhancement following administration of gadolinium. 1–3 In fact, the finding of

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Wouter I. Schievink, M. Marcel Maya, Franklin G. Moser, and James Tourje

S pontaneous intracranial hypotension is increasingly recognized as a noteworthy cause of new daily persistent headaches, 2, 4, 6, 7, 13, 14, 17, 20–22, 25, 29 although its initial misdiagnosis remains common. 22 Its cause is a spontaneous spinal CSF leak often associated with an underlying generalized connective tissue disorder. 24, 25, 27 Pachymeningeal enhancement and downward displacement of the brain are the most characteristic imaging findings in intracranial hypotension. 4, 11–14, 23, 25 Another important imaging feature is a subdural fluid

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E. Scott Conner, Antonio V. Lorenzo, Keasley Welch, and Brent Dorval

coincident and possibly causally related to a generalized tissue dehydration that is known to occur. 34 Subsequently, in 1978, 32 Welch formulated the hypothesis that the negative ICP resulting from an inordinate loss of fluid from the brain was the force responsible for spontaneous intracranial bleeding in the premature infant, a suggestion supported later by Coulter (unpublished data, 1980) and more recently by de Courten and Rabinowicz. 4 To assess the possibility that intracranial hypotension may be the underlying force in neonatal IVH, we induced such hypotension

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Neurosurgical Forum: Letters to the Editor To The Editor Eiji Moriyama , M.D. Ayumi Nishida , M.D. National Hospital Organization Fukuyama Medical Center Fukuyama, Hiroshima, Japan 964 965 Abstract Spontaneous intracranial hypotension due to a cerebrospinal fluid (CSF) leak in the spine is an important cause of new, daily persistent headaches. Most patients respond well to conservative treatments including epidural blood patching. Limited options for effective treatment are available for