CSFHypotension - Grand Rounds Grand Avi Schiowitz D.O Case...

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Unformatted text preview: Grand Rounds Grand Avi Schiowitz, D.O. 4/24/07 Case Presentation Case Chief Complaint Pt is a 37 y/o female who presented to the ED on 2/17/07 presented with a complaint of a constant pressure like headache which had lasted for the last 2 weeks. The headaches awoke her from sleep. headaches History of Present Illness History Onset Onset was 2/4/2007. At first got better with OTC medication, At now is constant. now Pt describes headaches as a tight feeling Pt bifrontal, extending posterior, left side hurts more than right. hurts Exacerbated by light and in the sitting, Exacerbated standing position. standing Relieved somewhat by lying flat. HPI cont. HPI Complains Complains of new onset nausea and vomiting. vomiting. Patient felt lightheaded for last few days, Patient “nearly walking into walls”. “nearly Unable to perform daily activities or go to Unable work. work. Pt was seen in OSH – SWGH twice during Pt last 2 weeks for same condition. Allergies: Latex PMHx: denies PSHx: C/S twice under spinal. PSHx: Social Hx: Non-smoker, social drinker, Social denies drug use Takes no medications. In the ED In Physical Physical exam: BP 144/81, HR 77, T 96.8, RR 14, 99% RA Gen: Pt lying on cot, cloth covering her face. Gen Pt Slow to move but is A & O x 3. Winced to light being turned on, but no photophobia to fundoscopic exam. fundoscopic Neuro: CN’s normal and intact. 5/5 strength and Neuro CN’s motor in UE/LE. Movement is slightly slow but not clumsy. not Rest of physical exam normal. Hospital Course Hospital IV IV started. 1 liter NS bolus given, second liter running. liter CBC, BMP and urine Hcg ordered. CT Head without contrast and CT angio of CT head ordered. head Pt given pain meds with slight Pt improvement. improvement. Pt Pt admitted to 9C Diagnosis of Headache, Pain control and Diagnosis dehydration. Neurology consult requested. Differential diagnosis of Acute Headache. Headache. Migraine Tension HA Cluster HA Stroke Subarachnoid Subarachnoid Hemorrhage Hemorrhage Intracerebral Intracerebral Hemorrhage Hemorrhage Cerebral Infarction Arterial Arterial Dissection – Carotid or Vertebral Carotid Acute Hydrocephalus Meningitis Encephalitis Giant Cell Arteritis Tumor Trauma Neurology consult Neurology Pt seen by neurologist next day. History consistent with that given in ED. No visual disturbances No tinnitus or diplopia. No history of trauma. Neurology Exam Neurology ROS negative Physical Exam WNL Neurologic Exam: A & O x 3 , CN intact CN Motor, sensation, coordination – WNL Reflexes 2+ & symmetric Gait normal, no romberg. Imaging Imaging CT CT of head – slit like ventricles and low lying cerebellar tonsils. Findings could be either due to pseudotumor cerebri with coexistent Chiari I malformation or CSF hypotension. hypotension. Imaging Imaging CT CT Angio of brain – Negative except for somewhat prominent venous structures supplying the transverse sinuses bilaterally. Findings could be manifestation of CSF hypotension syndrome. Although given the plain CT results pseudotumor cerbri also warrants consideration. Most significantly, no evidence of dural sinus thrombosis. thrombosis. Pseudotumor cerebri Pseudotumor AKA Benign Intracranial hypertension Defined as a syndrome of elevated ICP without Defined evidence of hydrocephalus, focal lesions or frank brain edema. brain Usually occurs in obese women between ages Usually 15-45. 15-45. Symptoms include HA, visual disturbances, or Symptoms diplopia secondary to abducens nerve palsies. diplopia Fundoscopic exam shows papilledema. Pseudotumor cerebri Pseudotumor Usually a benign and self limiting disorder. Condition associated with drugs such as Condition Vit A intoxication, Danazol, Accutane, Tetracyclines, oral contraceptives and corticosteroid withdrawal. corticosteroid Systemic disorders include Systemic hypoparathyroidism, lupus. hypoparathyroidism, CT of head can show small ventricles Treatment includes carbonic anhydrase Treatment inhibitors – reduce CSF production. Corticosteroids, Lasix. Corticosteroids, Weight loss. Correct underlying systemic disorder. In the most severe cases In Ventriculoperitoneal shunt can be done. Ventriculoperitoneal Radiology Radiology Impression: Orthostatic HA suspect spontaneous low CSF pressure HA. HA. Neurology Recommendation: Trial of caffeine 500mg IV. If no relief in 1 hour give 2nd dose. If no relief in AM will do MRI give of head. of MRI MRI of head done – Results show inferior displacement of the brainstem and cerebellum towards the foramen magnum with diffuse dural venous enhancement. Findings most consistant with intracranial hypotension. hypotension. Neurology recommends epidural blood Neurology patch and Anesthesia was consulted. patch Acute Acute pain service saw the patient and recommended conservative treatment at this time. this Abdominal binder, caffeine, fluids and Abdominal percocet for pain. percocet Patient was referred to Chronic pain for Patient followup. followup. Patient was discharged on 2/20/07. Instructed to follow with chronic pain and Instructed neurology as outpatient. neurology Told to come to ED if symptoms do not Told improve. improve. What is Intracranial Hypotension? What Escape Escape of fluid that normally surrounds the brain and spinal cord. the Usually characterized by an orthostatic Usually headache – one that worsens with sitting or standing. or Headache can be chronic or patient can Headache present without headache. present Location of headache varies between Location patients. patients. Headaches in intracranial hypotension hypotension Orthostatic Acute Acute thunderclap onset of orthostatic Cervical or Cervical HA HA interscapular pain that Second half of day preceds orthostatic Second HA HA HA HA Lingering non Paradoxic orthostatic Lingering Paradoxic orthostatic HA HA orthostatic HA Exertional HA wihout No HA Exertional orthostatic features orthostatic Cause of Headache Cause CSF supports the brain. Brain weight of 1500gr in air weighs only 48gr in Brain the cranium. the Remaining weight supported by pain sensitive Remaining structures. Meninges, cerebral and cerebellar veins, CN V, VII, IX and X, upper 3 cervical nerves. nerves. CSF decreases – decrease in buoyancy causing CSF traction on these structures. traction In the upright position the downward In displacement is exagerated. displacement Evidence Evidence of this theory is supported first by study data documenting downward displacement of cranial structures. of Evidence in support of this theory comes from Evidence data collected by Kunkle, et al who induced postural HA in healthy volunteers by draining CSF. One of his subject had undergone a section of the roots of CN V and IX and upper 4 cervical roots on L side with analgesia in the regions to which these nerves project. This pt experienced HA only on right side. experienced Another Another theory proposes the dilitation of the intracranial vascular structures causes the headaches. This is based on the Monroe-Kellie hypothesis which states that the sum of the volumes of intracranial blood, CSF and brain tissue must remain constant in an intact cranium. According to this hypothesis a loss of CSF will cause an increase in intracranial blood volume. increase Most Most compensation occurs via venous dilitation due to greater compliance and capacitance. capacitance. Venous sinus engorgement, Venous pachymeningeal enhancement, subdural effusions and enlargement of pituitary gland may represent compensatory changes to maintain intracranial volume. changes Pain is exacerbated by: Laughing Coughing Sneezing Jugular Venous Compression Valsalva maneuver Analgesics have minimal effect and pain is Analgesics usually relieved with lying flat. Other Symptoms: Other Nausea Vomiting Anorexia Neck pain Dizzyness Diplopia Photophobia Changes in hearing Unsteadiness Unsteadiness or staggering gait Facial numbness or Facial weakness weakness Transient visual Transient obscuration obscuration Upper limb radicular Upper symptoms symptoms Rare symptoms Rare Galactorrhea Stupor Ataxia Parkinsonism Coma Result Result of compression of pituitary stalk, diencephalon, posterior fossa, and midline structures. structures. Etiology of CSF volume depletion Etiology True Hypovolemic state – reduced total body water CSF shunt overdrainage CSF leaks: CSF Traumatic: Traumatic: After definite trauma Spinal tap or epidural Spinal or cranial surgery Spontaneous: Unknown cause – most common weakness of the dural sac – ex. Meningeal weakness diverticula or connective tissue abnormalities diverticula This This patient was diagnosed with spontaneous CSF hypotension. Syndrome recognized for more than 55 Syndrome years years First proposed by Schaltenbrand in 1938 First and described as a headache syndrome virtually identical to one following an LP. virtually Proposed the following mechanisms: 1. Decreased CSF production 2. Increased CSF absorption 3. CSF Leakage through small tears Today the accepted etiology is of CSF Today leakage. leakage. Most occur at the cervicothoracic junction Most and thoracic levels. and Can Can be attributed to minor trauma such as fall, sneezing, sudden twist or stretch. fall, Can cause rupture of preexisting spinal Can epidural cysts or tarlov cysts or tear in dural nerve sheath. dural Diagnosis Diagnosis CSF CSF analysis – opening pressure can be low – around 60mmhg. around Dry taps are encountered Rare instances the was negative pressure – Rare sucking noise as stylet is removed. sucking CSF is typically clear. Protein concentration CSF normal or high. WBC count can be normal or high. Cytology and microbiology are always normal Glucose concentration is never low. CT CT of head is of limited value. It might show subdural fluid collections. Used more to rule out other causes. to MRI will show diffuse pachymeningeal MRI enhancement following the administration of gondolinium. This is the most characteristic feature of this syndrome. characteristic MRI findings in SIH MRI Diffuse pachymeningeal enhancement. Descent of brain – Cerebellar tonsils, obliteration Descent of some subarachnoid cisterns, crowding of post. Fossa post. Enlargement of pituitary Flattening or tenting of optic chiasm Subdural fluid collections Engorged cerebral venous sinuses Decreased size of ventricles In In the spine – extra arachnoid fluid collections collections Meningeal diverticula ID of level of leak ID of actual leak site – rare Engorgement of epidural veins Spinal pachymeningeal enhancement CT Myelogram – used to demonstrate CSF leaks and is CT the study of choice to find its location. the Radioisotope cisternography – Uses indium-111. Radioisotope introduced intrathecally and its movement is followed by sequential scanning at certain time intervals. Normally by 24 hours radioactivity can be detected over Normally the cerebral convexities. If there is a CSF leak there will be minimal activity. If Early accumulation will be detected in the kidneys and Early bladder bladder Treatment of CSF leaks Treatment HA usually resolve with conservative treatment within 212 days. Bed rest – supine position reduces CSF pressure at leak Bed site and promote meningeal healing. site Fluids – increases CSF volume by fluid restoration. increases Caffeine – Thought to produce arterial vasoconstriction through blockade of adenosine receptors. Intracranial blood flow venous engorgement are decreased. blood Steroids – effort to restore CSF volume. No evidence Steroids indicates that steroids have any effect on CSF Production or absorption. Abdominal binder Treatment Treatment Other treatment options include: Epidural Blood Patch Continuous epidural saline infusion Epidural infusion of dextran Epidural injection of fibrin glue Intrathecal fluid injection Surgical correction Epidural blood patch Epidural According According to Mokri, epidural blood patch is the treatment of choice in individuals who have failed conservative therapy. Technique introduced by Gormley who Technique observed that the incidence of ICH following a lumbar puncture is less in individuals when the LP is traumatic and bloody. bloody. Study Study by Mokri, Sencakova, and McClelland identified 54 patients with SIH. 29 patients received EBP 4 Patients were eliminated. Followup was obtained via review of Followup records, correspondence and phone calls. records, Ages ranged for 18 to 62. 20 women 5 Ages men. men. All All patients received EBP using 10 -20ml of blood of First EBP 9 out of 25 improved. 15 who failed first EBP underwent 2nd. 5 reponded well. Of the 10 remaining, 2 were treated Of surgically. Remainder underwent a 3rd surgically. EBP 4 responded well. 4 other underwent surgical correction. surgical This This technique involves injecting blood into the epidural space. epidural Pt experiences immediate relief due to volume Pt replacement. In spontaneous CSF leaks patients usually In require more than one blood patch. require Procedure is most effective is done at level of Procedure leak. leak. If level unknown – blood can be injected into If lumbar space and pt head can be lowered to allow the blood to ascend. Data indicates that this might be effective over 9 spinal segments this Complications Complications Most Most common complication is back discomfort at injection site – 30% discomfort Paresthesia Radiculopathy Chemical meningitis Pt Pt arrives back in ED on 2/28/07 with worsening of HA. worsening Pt is actively vomiting. HA is continuous Pt and getting worse. and Pt was compliant with abdominal binder, Pt caffeine, fluids. Pain meds give mild relief. Pt admitted to 9C. Neurology and Pt Anesthesia consulted. Anesthesia Anesthesia Anesthesia Acute Pain Service went to evaluate pt. on 9C. evaluate Risks and Benefits of epidural blood patch Risks discussed at length. All question were asked and answered. asked Pt wanted to try a trial of steroids prior to Pt epidural blood patch. epidural On On 3/2/07 pt was brought to OR for epidural blood patch under fluoroscopy. blood Epidural space was identified and 3cc of blood Epidural was injected. Pt states that she has immediate resolution of Pt symptoms. symptoms. Post op – pt sitting in bed. Denies HA, denies Post N/V. N/V. Pt discharged home. Follow with neurology and Pt chronic pain as needed. chronic 3/9/07 pt calls MHMC complaining of HA. Pain no longer occipital. Only bifrontal Pain L>R. L>R. Has nausea and vomiting. Sees neurology and a 2nd epidural blood patch is recommended. Pt started on steroids – 8mg Decadron for 5 days. steroids Repeat Repeat CT of head shows cerebellar tonsils inferiorly displaced within the foramen magnum. 4th ventricle appears foramen small. Findings consistent with intracranial hypotension. hypotension. Chronic pain was consulted by neurology. Recommendations by chronic pain were to start Recommendations cafergot TID, abdominal binder, phenergan for nausea. nausea. Will do epidural blood patch – 15ml of blood. If no response, CT myelogram to evaluate were If CSF leakage is. Rupture of Tarlov cyst. CSF F/U one week after procedure. Epidural Epidural blood patch done on 3/19/07. 15ml blood injected in epidural space. Resolution of symptoms. Pt followed up on April 3 with chronic pain. Pts symptoms have improved. Still has a mild Pts HA but is functional. HA No further treatment needed at this time. If HA returns – pt to undergo CT myelogram. ...
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