Dados do Trabalho

Título

Myelography in intracranial hypotension syndrome: from diagnosis to blood patch

Introdução e objetivo(s)

To discuss the intracranial hypotension syndrome, its clinical manifestations, and imaging findings; to present the specificities and techniques of imaging through MRI and myelotomography and their specific protocols; to showcase the treatment methods for cerebrospinal fluid leaks, particularly focusing on blood patches.

Método(s)

A literature review was conducted in the PUBMED library on the topic, and cases were selected from the service's archive, showcasing findings related to the disease, its diagnostic approach, and treatment stages.

Discussão

According to the International Classification of Headache Disorders (ICHD-3), SIH headache is defined as orthostatic headache caused by low cerebrospinal fluid (CSF) pressure (either spontaneous or secondary), usually accompanied by neck pain, tinnitus, changes in hearing, photophophia and/or nausea. As traumatic cases are easily linked to its clinical history, diagnosis turns difficult when “spontaneous” causes are suspected. Imaging tests have an important role on investigation and confirmation, allowing to identify and localize SIH probable cause. MRI plays an important role in detecting intracranial manifestations of SIH and spinal longitudinal epidural collections (SLEC), but cannot provide reliable indication to the exact site of the spinal CSF leak. CT myelography can be used in the diagnosis of CSF leaks in all spinal segments, specially dynamic/ultrafast CTM. By performing acquisitions with a short time interval between them, together with the change in decubitus, it is possible to monitor the flow of contrast according to gravity, and thereby identify its early penetration in dura mater tears ("fast-leaks") . Nonetheless, there are leaks that do not depend only on temporal resolution, but on the contrast medium concentration gradient and a certain amount of time for extravasation to occur. This group includes leaks CSF venous fistulas, better evaluated on the decubitus CTM. After determining cause and topography of the CSF-leak, treatment options range from non-invasive methods to surgical corrections. When initial conservative approaches fail to resolve symptoms and for moderate and severe cases, autologous epidural blood patching (EBP) should be considered.

Conclusões

A good diagnostic, localization and treatment of CSF leaks using techniques described in this presentation is determinant to enhance the success of interventional therapy.

Palavras Chave

Intracranial hypotension syndrome; myelography; blood patching

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