Chronic cerebellar hemorrhage in spontaneous intracranial hypotension: association with ventral spinal cerebrospinal fluid leaks

Clinical article

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Object

Spontaneous intracranial hypotension is an important cause of new-onset daily persistent headache. Cerebellar hemorrhage has been identified as a possible feature of spontaneous intracranial hypotension. The authors reviewed the MR imaging studies from a group of patients with spontaneous intracranial hypotension to assess the presence of cerebellar hemorrhage.

Methods

Medical records and radiological images were reviewed in 262 cases involving patients with spontaneous intracranial hypotension who had undergone MR imaging of the brain as well as spinal imaging.

Results

Chronic cerebellar hemorrhages were found in 7 (2.7%) of the 262 patients with spontaneous intracranial hypotension. These hemorrhages were found in 7 (19.4%) of the 36 patients with a ventral spinal CSF leak and in none of the 226 patients who did not have such a CSF leak (p < 0.0001). The degree of hemosiderin deposits was variable, ranging from mild involvement of the cerebellar folia to widespread superficial siderosis. Only the 1 patient with superficial siderosis had symptoms due to the hemorrhages. The time period between the onset of symptoms due to spontaneous intracranial hypotension and MR imaging examination was significantly longer in those patients with cerebellar hemorrhage than in those with a ventral spinal CSF leak and no evidence for cerebellar hemorrhage (mean 19.6 years vs 2.3 months, p < 0.0001).

Conclusions

Chronic cerebellar hemorrhage should be included among the manifestations of spontaneous intracranial hypotension. The severity is variable, but the hemorrhage generally is asymptomatic. The underlying spinal CSF leak is ventral and mostly of long duration.

Article Information

Address correspondence to: Wouter I. Schievink, M.D., Department of Neurosurgery, Cedars-Sinai Medical Center, 8631 West Third Street, Suite 800E, Los Angeles, California 90048. email: SchievinkW@cshs.org.

Please include this information when citing this paper: published online July 8, 2011; DOI: 10.3171/2011.5.SPINE10890.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A–D: Sagittal, axial, and coronal T2-weighted MR images showing diffuse supra- and infratentorial hemosiderin staining. Note the dark etching along the surfaces of the brainstem and the cerebellar folia as well as cortical surfaces, typical of superficial siderosis. E and F: Sagittal and axial spinal T2-weighted MR images showing a ventral epidural CSF collection (arrows). Also, note hemosiderin staining along the spinal cord.

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    A and B: Axial and sagittal T2-weighted MR images showing symmetrical signal hypointensities in the superior cerebellum (arrows) consistent with hemosiderin. C and D: Sagittal and axial T2-weighted spinal MR images showing a ventral CSF collection (arrows).

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    A: Sagittal T1-weighted MR image showing brain sagging with inferior displacement of cerebellar tonsils (arrow). Note the downward displacement of the optic chasm and distortion of brainstem. B and C: Axial T2-weighted and coronal gradient echo MR images showing symmetrical linear and punctate signal changes of hemosiderin along the vermis and cerebellar hemispheres. D–F: Sagittal and axial T2-weighted MR images (D and E, respectively) and CT myelogram (F) showing the ventral epidural CSF collection (arrows).

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    A: Axial T1-weighted MR image showing diffuse pachymeningeal enhancement. B: Axial T2-weighted MR image revealing subtle hypointense signal in the upper cerebellar folia. C and D: Coronal gradient echo MR images demonstrating accentuation of the abnormal dark signal (arrows) related to chronic hemosiderin. E and F: Sagittal and axial T2-weighted MR images showing a ventral epidural CSF collection.

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    A: Sagittal T1-weighted image showing brain sagging with flattening of the pons (arrow). B: Axial T2-weighted MR image revealing linear dark signal in the upper vermis (arrows). C–F: Coronal gradient echo, axial susceptibility-weighted, and sagittal gradient echo MR images demonstrating accentuation of the signal loss due to hemosiderin in the cerebellar vermis and upper folia. G and H: Sagittal and axial T2-weighted MR images showing the ventral epidural CSF collection (arrows).

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    A: Axial T1-weighted MR image showing diffuse pachymeningeal enhancement. B: Axial gradient echo MR image showing linear dark signal along the superior cerebellar folia. C and D: Digital subtraction myelogram (C) showing the leakage site (arrow) and resultant ventral fluid collection, that is confirmed on the axial CT myelogram (D, arrow).

  • View in gallery

    A: Axial T1-weighted MR image shows diffuse pachymeningeal enhancement. B and C: Coronal gradient echo MR images demonstrate punctate and linear foci of dark signal (arrows) indicating chronic hemosiderin staining. D and E: Sagittal T2-weighted MR and axial CT myelogram images show a ventral epidural CSF collection (arrows).

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