Treatment of Spontaneous Intracranial Hypotension Secondary to C-2 Meningeal Cyst by Surgical Packing-Case Report-

Abstract

A 41-year-old man presented with progressive worsening of postural headache. Computed tomography (CT) showed bilateral subdural hematomas without prior history of trauma. The diagnosis was spontaneous intracranial hypotension (SIH). Conservative treatment with oral steroids failed to prevent gradual deterioration of the patient's consciousness. CT myelography revealed massive cerebrospinal fluid (CSF) leakage between the C-1 and C-2 levels. The leak was repaired surgically via a laminectomy. A cyst, thought to be a meningeal cyst, was discovered adjacent to the right C-2 nerve root, and CSF was seen seeping out from around the cyst after a Valsalva maneuver. The presumed dural defect of the cyst was sealed by packing with muscle fragments and fibrin glue. The symptoms disappeared soon after surgery. He was discharged 1 month after surgery without deficits. Most SIH cases are benign and can be managed conservatively, or by the epidural blood patch method. Surgery is more invasive than the epidural blood patch method, but should be performed in patients with a high cervical lesion and massive CSF leakage.

Spontaneous Intracranial Hypotension Presenting Without Orthostatic Headache Complicated by Acute Subdural Hematoma After Drainage for Chronic Subdural Hematoma-Case Report-

“…Whether medically intractable CSF leakage at C1-2 is common remains controversial, 17) but spine surgery or other special techniques for EBP to stop the leakage are efficacious in cases refractory to ordinary EBP from the lumbar spine. 8,9,11) SIH patients with concomitant CSDH seem to complain of orthostatic headache less frequently than those without CSDH. 3,13,18) Therefore, the presence of CSDH may prevent orthostatic headache from developing by correcting the abnormally low intracranial pressure (ICP) or volume.…”

“…Measures to stop CSF leakage, particularly EBP, are required to precede CSDH drainage. 4,8,19) Small CSDH may resolve spontaneously after successful treatment of SIH. Nevertheless, CSDH drainage may have to be performed emergently in patients with impending brain herniation.…”

Application of time-spatial labeling inversion pulse magnetic resonance imaging in the diagnosis of spontaneous intracranial hypotension due to high-flow cerebrospinal fluid leakage at C1-2

“…In this context, surgical exploration for a dural laceration or meningeal diverticula via a C1 hemilaminectomy under operative microscope may be warranted as a safe and effective treatment for high-flow CSF leakage at C1-2 refractory to medical treatment. [3716] Thus, injury to the epidural venous plexus may be minimized and dural repair can be performed on a case-by-case basis. There may be criticism of the treatment strategy used in the present case, in that it may have been better if an epidural blood patch had been attempted prior to resorting to surgery.…”

Spontaneous C1-2 CSF Leak Treated with High Cervical Epidural Blood Patch

“…7,9 At higher levels, a surgical approach is recommended. 10,11 Concern about a high cervical epidural blood patch is related to a high rate of discontinuity of the ligamentum flavum in the cervical region. 17 In this region, imaging-guided needle insertion has been suggested.…”

“…[7][8][9] However, leakage at C1-2 is usually managed with surgical repair. [10][11] One case report described the use of an epidural blood patch at the C2 level performed under CT guidance. 12 We report a case in which a patient with CSF leakage at C 1-2 was successfully treated with a high cervical epidural blood patch under fluoroscopic guidance.…”