Primary and Secondary Intracranial Hypotension:  Clinical, MRI and Radioisotope Cisternography Findings

Naime Altınkaya; Tülin Yıldırım; Deniz Yerdelen; Başak Karakurum; Ali Fuat Yapar; Özlem Alkan

Naime Altınkaya¹, Tülin Yıldırım¹, Deniz Yerdelen², Başak Karakurum², Ali Fuat Yapar³, Özlem Alkan¹

¹Faculty Of Medicine, University Of Baskent, Department Of Radiology, Adana, Turkey
²Faculty Of Medicine, University Of Baskent, Department Of Neurology, Adana, Turkey
³Faculty Of Medicine, University Of Baskent, Department Of Nuclear Medicine, Adana, Turkey

Keywords: Intracranial hypotension, spontaneous, secondary, headache, magnetic resonance imaging, myelographic cisternography

Abstract

OBJECTIVE: It was aimed to evaluate the clinical features, magnetic resonance imaging (MRI) and radioisotope cisternography findings and results of the treatment in intracranial hypotension.

METHODS: Fifteen patients diagnosed with intracranial hypotension were evaluated retrospectively. The opening pressure and analysis of cerebrospinal fluid (CSF), cerebral and spinal MRI and radioisotope cisternography findings, clinical features, and results of the treatment are discussed.

RESULTS: The mean age of 15 patients, 11 women and 4 men, was 37 years. Eleven patients had spontaneous (primary) and 4 had secondary intracranial hypotension. Fourteen (93.3%) patients had orthostatic headache, and 1 (6.6%) patient’s headache did not have a postural feature. In addition to the headache, 5 (33.3%) patients had nausea and vomiting, 1 patient had diplopia, 1 had neck pain, and 1 had vertigo. Cerebral MRI revealed dural thickening in 12 (85.7%) patients, enlarged hypophysis in 5 (35.7%) patients, brain sagging in 3 (21.4%) patients, subdural hematoma in 2 (14.2%) patients, and subdural effusion in 2 (14.2%) patients. Spinal MRI was normal in 5 (83.3%) of 6 patients, and it showed meningeal thickening in 1 (16.6%). Radioisotope cisternography revealed CSF leak in 8 (88.8%) of 9 patients. CSF opening pressure was ≤ 60 mmH2O in 8 (88.8%) of 9 patients. CSF protein was increased in 3 patients. Complete improvement was obtained with conservative treatment in 8 (53.3%) patients. Seven (46.6%) patients who did not improve with conservative treatment were administered epidural blood patching, and 6 of these 7 patients improved completely.

CONCLUSION: Orthostatic headache, low CSF opening pressure and characteristic MRI findings are essential criteria for diagnosis of intracranial hypotension. Radioisotope cisternography is useful to detect CSF leak. In patients who do not improve with conservative treatment, autologous blood patch should be applied.