Hipertension

Páginas: 22 (5354 palabras) Publicado: 25 de septiembre de 2011
J Neurosurg 112:300–306, 2010

Spontaneous intracranial hypotension syndrome: a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients
Clinical article
Angelo FrAnzini, M.D.,1 giuseppe MessinA, M.D.,1 VittoriA nAzzi, M.D.,1 eliAnA MeA, M.D., 2 MAssiMo leone, M.D., 2 luisA ChiAppArini, M.D., 3 gioVAnni Broggi, M.D.,1 AnD gennAro Bussone,M.D. 2
Departments of 1Neurosurgery, 2Neurology, and 3Neuroradiology, Istituto Nazionale Neurologico “Carlo Besta,” Milan, Italy
Object. Spontaneous intracranial hypotension (SIH) is a potentially serious pathological syndrome consisting of specific symptoms and neuroradiological signs that can sometimes be used to assess the efficacy of the treatment. In this paper the authors report a seriesof 28 patients with this syndrome who were all treated with an epidural blood patch at the authors’ institution. The authors propose a novel physiopathological theory of SIH based on some anatomical considerations about the spinal venous drainage system. Methods. Between January 1993 and January 2007, the authors treated 28 patients in whom SIH had been diagnosed. Twenty-seven of the 28 patientspresented with the typical findings of SIH on brain MR imaging (dural enhancement and thickening subdural collections, caudal displacement of cerebellar tonsils, and reduction in height of suprachiasmatic cisterns). The sites of the patients’ neuroradiologically suspected CSF leakage were different, but the blood patch procedure was performed at the lumbar level in all patients. The patients werethen assessed at 3-month and 1- and 3-year follow-up visits. At the last visit (although only available for 11 patients) 83.3% of patients were completely free from clinical symptoms and 8.3% complained of sporadic orthostatic headache. Results. The authors think that in the so-called SIH syndrome, the dural leak, even in those cases in which it can be clearly identified on neuroradiologicalexaminations, is not the cause of the disease but the effect of the epidural hypotension maintained by the inferior cava vein outflow to the heart. The goal of their blood patch procedure (a sort of epidural block obtained using autologous blood and fibrin glue at the L1–2 level) is not to seal CSF leaks, but instead to help in reversing the CSF-blood gradient within the epidural space along the entirecord. Conclusions. The authors’ procedure seems to lead to good and long-lasting clinical results. (DOI: 10.3171/2009.6.JNS09415)

Key WorDs      •      orthostatic headache      •      spontaneous intracranial hypotension      •      blood patch

T

spontaneous or idiopathic CSF hypotension (also known as SIH) syndrome is characterized by specific symptoms and specific neuroradiologicalpatterns. The most common symptom is orthostatic headache (which is relieved when the individual lies down), and is often associated with nausea, vomiting, dizziness, diplopia, photophobia, hearing impairment, neck stiffness, and blurred vision.8 Brain MR imaging findings include intracranial pachymeningeal thickening and postcontrast enhancement, subdural fluid collections, and hematomas (possiblyleading to severe neurologihe

Abbreviation used in this paper: SIH = spontaneous idiopathic hypotension.

cal impairment with a decreased level of consciousness and acute deterioration)2 and downward displacement of the cerebellar tonsils or “sagging” of the brain.7,8,11 Another 2 MR imaging patterns that were recently noted in such patients are the increased mean diffusivity (on MR imagingdiffusion studies), associated with swelling, in the diencephalic-mesencephalic structures draining into the cerebral deep venous system, and the decrease of the angle formed by the vein of Galen and straight sinus.13 In most patients a true CSF leak between the subarachnoid and subdural spaces occurring at 1 or more spinal levels through dural tears is demonstrated by spinal MR imaging, myelo-MR...
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