Journal of the Korean Society of Radiology (대한영상의학회지)

The Korean Society of Radiology (대한영상의학회)
권호 표지
DOI QR코드

DOI QR Code

Spinal Presentation of Spontaneous Intracranial Hypotension

자발두개내압저하의 척추 자기공명영상 소견

  • Hye Jin Yoo (Department of Radiology, Seoul National University Hospital)
  • 류혜진 (서울대학교병원 영상의학과)
  • Received : 2023.12.04
  • Accepted : 2024.01.08
  • Published : 2024.01.01
Download PDF
⟨ Previous Next ⟩

Abstract

Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and heightened awareness. Many prior studies have reported the characteristic brain MRI findings of SIH. However, recently, focus has shifted to spinal MRI, as SIH is believed to be caused by leakage of cerebrospinal fluid from the spinal dural sac. Advanced techniques such as ultrafast CT myelography and digital subtraction myelography have emerged as useful technique to identify the site of cerebrospinal fluid leakage. In this review, we discuss the diagnosis, spinal MRI findings, imaging techniques, and treatment of SIH.

자발두개내압저하(spontaneous intracranial hypotension)은 기립성 두통을 특징으로 하는 질환이며, 영상기법의 발달과 질환에 대한 인식이 높아짐에 따라 발견 빈도가 점차 증가하고 있는 추세이다. 이전에는 이 질환에서의 특징적인 뇌 자기공명영상 소견들이 많이 알려져 있었다. 그러나 최근에는 척추에서의 뇌척수액 누출이 원인으로 알려짐에 따라 척추 자기공명영상 소견이 주목받고 있다. 또한 뇌척수액 누출 부위를 정확히 확인할 수 있는 초고속 CT 척수조영술(ultrafast CT myelography), 디지털 감산 척수조영술(digital subtraction myelography) 등이 개발되었다. 이 종설에서는 자발두개내압저하의 진단, 척추 자기공명영상 소견, 최신 영상검사법과 치료에 대해 다루고자 한다.

Keywords

References

  1. Goddu Govindappa SK, Adiga CP, Kumar S, Goolahally LN, Kumar S. Spontaneous intracranial hypotension: a review of neuroimaging and current concepts. Indian J Radiol Imaging 2023;34:128-138  https://doi.org/10.1055/s-0043-1774301
  2. Dobrocky T, Nicholson P, Hani L, Mordasini P, Krings T, Brinjikji W, et al. Spontaneous intracranial hypotension: searching for the CSF leak. Lancet Neurol 2022;21:369-380  https://doi.org/10.1016/S1474-4422(21)00423-3
  3. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 2006;295:2286-2296  https://doi.org/10.1001/jama.295.19.2286
  4. Schievink WI, Maya MM, Louy C, Moser FG, Tourje J. Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol 2008;29:853-856  https://doi.org/10.3174/ajnr.A0956
  5. Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia 2018;38:1-211  https://doi.org/10.1177/0333102417738202
  6. Mokri B. The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology 2001;56:1746-1748  https://doi.org/10.1212/WNL.56.12.1746
  7. Sun-Edelstein C, Lay C. Spontaneous intracranial hypotension: pathophysiology, clinical features, and diagnosis. Available at. https://www.uptodate.com/contents/spontaneous-intracranial-hypotension-pathophysiology-clinical-features-and-diagnosis. Published 2023. Accessed November 19, 2023 
  8. Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol Sci 2001;192:1-8  https://doi.org/10.1016/S0022-510X(01)00601-3
  9. Farb RI, Nicholson PJ, Peng PW, Massicotte EM, Lay C, Krings T, et al. Spontaneous intracranial hypotension: a systematic imaging approach for CSF leak localization and management based on MRI and digital subtraction myelography. AJNR Am J Neuroradiol 2019;40:745-753  https://doi.org/10.3174/ajnr.A6016
  10. Schievink WI, Maya MM, Jean-Pierre S, Nuno M, Prasad RS, Moser FG. A classification system of spontaneous spinal CSF leaks. Neurology 2016;87:673-679  https://doi.org/10.1212/WNL.0000000000002986
  11. Watanabe A, Horikoshi T, Uchida M, Koizumi H, Yagishita T, Kinouchi H. Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neuroradiol 2009;30:147-151  https://doi.org/10.3174/ajnr.A1277
  12. Medina JH, Abrams K, Falcone S, Bhatia RG. Spinal imaging findings in spontaneous intracranial hypotension. AJR Am J Roentgenol 2010;195:459-464  https://doi.org/10.2214/AJR.09.3289
  13. Chen CJ, Lee TH, Hsu HL, Tseng YC, Wong YC, Wang LJ. Spinal MR findings in spontaneous intracranial hypotension. Neuroradiology 2002;44:996-1003  https://doi.org/10.1007/s00234-002-0876-x
  14. Chiapparini L, Farina L, D'Incerti L, Erbetta A, Pareyson D, CarrieroM R, et al. Spinal radiological findings in nine patients with spontaneous intracranial hypotension. Neuroradiology 2002;44:143-150; discussion 151-152  https://doi.org/10.1007/s002340100685
  15. Tsai PH, Fuh JL, Lirng JF, Wang SJ. Heavily T2-weighted MR myelography in patients with spontaneous intracranial hypotension: a case-control study. Cephalalgia 2007;27:929-934  https://doi.org/10.1111/j.1468-2982.2007.01376.x
  16. Yousry I, Forderreuther S, Moriggl B, Holtmannspotter M, Naidich TP, Straube A, et al. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. AJNR Am J Neuroradiol 2001;22:1239-1250 
  17. Kranz PG, Luetmer PH, Diehn FE, Amrhein TJ, Tanpitukpongse TP, Gray L. Myelographic techniques for the detection of spinal CSF leaks in spontaneous intracranial hypotension. AJR Am J Roentgenol 2016;206:8-19  https://doi.org/10.2214/AJR.15.14884
  18. Kranz PG, Malinzak MD, Amrhein TJ, Gray L. Update on the diagnosis and treatment of spontaneous intracranial hypotension. Curr Pain Headache Rep 2017;21:37 
  19. Hyun SH, Lee KH, Lee SJ, Cho YS, Lee EJ, Choi JY, et al. Potential value of radionuclide cisternography in diagnosis and management planning of spontaneous intracranial hypotension. Clin Neurol Neurosurg 2008;110:657-661  https://doi.org/10.1016/j.clineuro.2008.03.014
  20. Thielen KR, Sillery JC, Morris JM, Hoxworth JM, Diehn FE, Wald JT, et al. Ultrafast dynamic computed tomography myelography for the precise identification of high-flow cerebrospinal fluid leaks caused by spiculated spinal osteophytes. J Neurosurg Spine 2015;22:324-331  https://doi.org/10.3171/2014.10.SPINE14209
  21. Lutzen N, Barvulsky Aleman E, Fung C, Beck J, Urbach H. Prone dynamic CT myelography in spontaneous intracranial hypotension: diagnostic need and radiation doses. Clin Neuroradiol 2023;33:739-745  https://doi.org/10.1007/s00062-023-01269-z
  22. Mamlouk MD, Shen PY, Dahlin BC. Modified dynamic CT myelography for type 1 and 2 CSF leaks: a procedural approach. AJNR Am J Neuroradiol 2023;44:341-346  https://doi.org/10.3174/ajnr.A7784
  23. Kranz PG, Gray L, Amrhein TJ. Decubitus CT myelography for detecting subtle CSF leaks in spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2019;40:754-756  https://doi.org/10.3174/ajnr.A5995
  24. Hoxworth JM, Trentman TL, Kotsenas AL, Thielen KR, Nelson KD, Dodick DW. The role of digital subtraction myelography in the diagnosis and localization of spontaneous spinal CSF leaks. AJR Am J Roentgenol 2012;199:649-653  https://doi.org/10.2214/AJR.11.8238
  25. Hoxworth JM, Patel AC, Bosch EP, Nelson KD. Localization of a rapid CSF leak with digital subtraction myelography. AJNR Am J Neuroradiol 2009;30:516-519  https://doi.org/10.3174/ajnr.A1294
  26. Luetzen N, Dovi-Akue P, Fung C, Beck J, Urbach H. Spontaneous intracranial hypotension: diagnostic and therapeutic workup. Neuroradiology 2021;63:1765-1772  https://doi.org/10.1007/s00234-021-02766-z
  27. Cho KI, Moon HS, Jeon HJ, Park K, Kong DS. Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch. Neurology 2011;76:1139-1144  https://doi.org/10.1212/WNL.0b013e318212ab43
  28. Sencakova D, Mokri B, McClelland RL. The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology 2001;57:1921-1923  https://doi.org/10.1212/WNL.57.10.1921
  29. Wu JW, Hseu SS, Fuh JL, Lirng JF, Wang YF, Chen WT, et al. Factors predicting response to the first epidural blood patch in spontaneous intracranial hypotension. Brain 2017;140:344-352 https://doi.org/10.1093/brain/aww328