The Key Issues In The Diagnosis And Treatment Of Spontaneous Intracranial Hypotension And Management Strategy Study

BackgroundSpontaneous intracranial hypotension(SIH)is a neurological disease known by orthostatic headacha It is caused by spontaneous cerebrospinal fluid(CSF)leaks and presented with headache and other associated symptoms at standing when brain tissue sinks due to CSF hypovolemia and buoyancy decrement.The diagnosis of SIH is based on clinical history,nauroimaging,CSF pressure and the effect of epidural blood patch(EBP).The aim of this study is to summarize the clinical data of 327 patients in our hospital and improve the understandi ng of SIH.Materials and Methods1.Demographic and clinical features of SIH1.1 Clinical data 327 patients with SIH treeited were collected in the SIH center of the Sir Run Run Shaw Hospital of Zhejiang University from 2008 to 2015.217 were female and 110 were male,with a female to male ratio at 1.97:1.The mean age was 40.71±10.15 years old,range 17-78.The median sage was 40 years old.The dignostic criteria for SIH delinested by the International Headache Classification(2nd edition,2004).1.2 Observational measurements:The course of disease,predisposing factors,clinical symptoms and signs,blcxxi pressure,CSF pressure and CSF lab results were observed The course of disease was divided into acute group(<15 day)and subacute/chronic group(?15 days).Associated symptoms induded nausea,vomiting,ear fullness,tinnitus,neck tstiffness,dizziness/vertigo,diplopia seizure and phonophobia1.3 Statistical methods:Independent samplet-test or One-way ANOVA,chi-square test,Fisher precise test and Speaman correlation analysis were used.2.Imaging for SIH diggnosis and CSF leaks localization2.1 Imaging of SIH:Subdural collection,diffuse meningexal enhancement,engorgement of cerebral venous sinuses,pituitary enlargement,sagging of brain,subdural hematoma,brain herniation,cerebral infarction,cerebral venous sinus thrombosis were observed.2.2 Methods for CSF leaks localization:computed tomography myelography(CTM),heavily T2-weighted mggnetic resonance myelography(MRM)and intrathecal gadolinium MR myelography(Gd-MRM)were used.2.3 Distribution of CSF leaks:The precise segments of CSF leaks were identified and classified as no leaks,pure cervical leaks,pure thoracic leaks,pure lumbar leaks,cervical + thoracic leaks,cervical + lumbar leaks,thoracic + lumbar leaks and cervical+ thoracic + lumbar leaks.The consistency of MRM and Gd-MRM findings was compared.2.4 Correldtion between CSF leaks segments and disease course/CSF pressure:Segments of CSF leaks indude no leak,a single spinal segment leak,and multiple spinal segments leaks.The correlation between the different types of CSF leaks and cours(9of disease as well as CSF pressure were compared.2.5 Neuroimaging in the failure ceCas of myelography:?he characteristic of cerebral MRI,MRM and other nauroimaging in the failure Case? of CTM or Gd-MRM were analyzed.2.6 Statistical methods:Independent sample t-test,chi-square test and Spearman cxorrelation analysi s were used.3.Risk factors for subdural hematoma(SDH)and clinical management strategies3.1 Clinical data All cases were divided into "SDH group" and "non-SDH group"according to whether the SDH revealed in cerebral CT or MR.3.2 Risk factors:The factors induding age,gender,illness duration,CSF pressure,diastolic blood pressure,spinal segment of CSF leaks and other factors were analyzed with univariate analysis.Then the multiple logilstic regressions were used to find the independent risk factors for SDH.3.3 Management strategies for SIH patients accompany with SDH:The effects of EBP and naurosurgery in SIH patients accompany with SDH were analyzed.The treatments strategies accompany with brain herniation were discussed.The dynamic absorption process of SDH was analyzed.3.4 Statistic methodcs:using independent samplet test,chi-square telst and multivariate logistic regression analysis were used.4.Effect of EBP and influencing factors4.1 Effect assessment of targeted EBP:the effect was evaluated by patient's pain scale reduction as satisfied or unsatisfied.The correlation between effect and gender,age,duration of disease,CSF pressure,SDH,subdural fluid collection,diffuse meningeal enhancement,EBP,surgery,spinal leak segments were studied.4.2 Statistics methods:multivariate logistic regression analysis was used.Results1.Demographic and clinical characteristics of SIH1.1 Correlation between gender and age:There were 110 male patients with an average age at 42.75 years old and 217 female patients with an average age at 39.67 years old.Male patients were elder than female patients(p<0.05).1.2 Course of disease:The course of disease was not significantly related to gender and age.1.3 Predisposing factors:Induding getting cold,trauma,massage,scraping,yoga,cough,fatigueand vaccination.1.4 Clinical symptoms and signs:Orthostatic headache appeared in all patients The most common accompanying symptoms were nausea,vomiting,neck stiffness and ti nnitus Female patients had more nausea than male(p<0.05).Patients younger than 40 years old had more nausea than those elder than 40 years old(p<0.05).1.5 Blood pressure and CSF pressure:56.1%patients CSF pressure were less than 60mmH2O.There were 5 Cases CSF pressure more than 200 mmH2O while 4 of them complicated with SDH and 1 of the four complicated with cerebral central herniation.Male patients had higher CSF pressure than female(p<0.05).The averge CSF pressure of patients with longer duration was slightly higher than those with shorter duration(p<0.05).There was a weak correlation between CSF pressure and systolic blood pressure.1.6 CSF lab results:The leukocyte and protein count in CSF were not significant related to the gender,age and the course of di sease of pstienta2.Imaging for SIH diagnosis and CSF leaks localization2.1 Cerebral imaging manifestations:Diffuse meningeal enhancement was most common(224 cases,74.4%).Male patients had more SDH than female(p<0.05).40 years elder patients had more SDH than younger patients(p<0.05).Patients with long course had a higher incidence for subdural fluids collection,SDH and diffuse meningeal enhancement.2.2 CSF leak localization:The most common CSF leaks were in the corvico-thoracic spire segments,followed by the pure cervical segments,pure thoracic segments and oervical+thoracd+lumbar segments CSF leaks simply involved lumbar segments or cervical+lumbar segments were rare.The results of MRM and Gd-MRM were relatively consistent in the judgment of CSF leaks while the results had high consistency in cervical segment.2.3 Correlation between the location of CSF leak segments and disease coursel CSF pressure:Patients with more spinal leak segments tended to have shorter course of disease and lower CSF pressure(p>0.05).2.4 Neuroimaging in the failure cases of CTM and Gd-MRM:The major manifestations indude:(1)Anterior and posterior roots of spinal cord were invisible when nerve roots went through contrast agent.(2)No dotted caudaequina in lumbar segment.(3)No diffuse contrast in the ventride and cistern;(4)Discrete drde-like contrast in cervico-thoracic spine segments.(5)Sgnals and densities of contrast were non-uniform.(6)The signal s outline in the contrast showed unsmooth.3.Risk factors for subdural hematoma and clinical treatment strategies3.1 General information of SIH patients with SDH:The incidence of SDH in SIH patients was 18%.3.2 Risl factors of SDH by using univariate analysis:elder,higher CSF pressure,male,long course,high systolic blood pressure(p<0.05).3.3 Risk factors of SDH by using multivariate analysis:Age and gender were i ndependent risk factors(RR=3.3 for male patients and RR=1.039 for age).3.4 Treatment strategies for SI H patients with SDH(1)SIH Patients with SDH had a higher rate and need more times of EBP than those without SDH.(2)More patients with SDH received EBP prior to neurosurgery.For patients combined with central brain hernia,the emergency surgery to evacuate subdural hematoma was done prior to EBP.(3)The SDH can be absorbed quiCkly after EBP.4.The effect of EBPand its influencing factors analysis4.1 Frequency distribution of EBP.45(13.8%)patients chose conservative treatment.282 patients received EBPfor 1-5 times.271 patients under targeted EBP while 11 Cases under non-targeded EBP.4.2 Factors affecting the result of treatment:There were 209(74.1%)patients got effective results in the total 282 with EBP treatments Gender,age,duration,CSF pressure,SDH,subdural fluids collection,diffuse meningeal enhancement,EBP times,neurosurgery,the number of spinal leak segment were not significantly related to effect.Conclusion(1)SIH usually occurs in the 40-year-old round patients.Females are more frequent involved than males.The age of onset iselder in male than female.(2)Orthostatic headache are the characteristic clinical features in SIH.The most common acxompanying symptoms of SIH are nausea,vomiting,neck stiffness and tinnitus.Women and patients younges than 40 present more symptoms.Near half of our SIH patients CSF pressure was in the normal range.Severe complications of SIH should be consided if patients CSF pressure exceed the normal range.(3)Subdural fluid collection,SDH and diffuse meningeal enhancement of imaging signs are more common in patients with longer disease course.The most common CSF leaks were in the cervico-thoracdc spine segments,followed by the pure cervical segments,pure thoracic segments and cervical+thoracic+lumbar segments.CSF leaks simply involved lumbar segments or carvical+lumbar segments were rare.The results of MRM and Gd-MRM were relatively consistent in thejudgment of CSF leaks whilethe results had high consistency in cervical segment.(4)SDH prefers to occur in male and elder than 40 patients of SIH.The incidence of SDH isassociated with age,CSF pressure,gender,disease duration and systolic blood pressure,where age and gender are independent risk factors.Some SIH patients with SDH needed EBP combined with neurosurgery treatments for good results.(5)The efficient of EBP is about 74.1%.However,the effect has no significant relation with gender,age,duration,CSF pressure,SDH,subdural fluids collection,diffuse meningeal enhancement,EBP times,neurosurgery and the number of spinal leak segment.