0:01

I did want to show you the spinal imaging of

0:04

the patient with intracranial hypotension.

0:07

This is the same patient. You see the herniation of

0:11

the cerebellar tonsil and the cerebellum downward

0:15

through the foramen magnum in a pattern that

0:17

was thought to represent Chiari I malformation,

0:21

with a decompression having been performed.

0:24

However, this patient's problem

0:26

was intracranial hypotension.

0:28

This herniation of the cerebellar tonsils led

0:31

to development of a cervical cord syrinx because

0:37

of the obstruction at the foramen magnum.

0:41

The other imaging features that you can

0:43

see on this sagittal T2-weighted scan is

0:46

reduction in the mamillopontine distance.

0:49

And that number I'm, I'm gonna have to

0:51

quote you, I think is 12 millimeters.

0:53

And in this patient it was six millimeters.

0:56

Here is the syrinx that had occurred secondary

1:00

to the tonsil herniation, obstructing CSF flow.

1:05

For patients who have intracranial hypotension, you

1:07

wanna look into the neuroforamina and see whether there

1:10

are nerve root sleeve cysts that may be enlarged or

1:14

have ruptured or other sources of CSF leakage in the

1:20

dura, which may occur post-op after spine surgery.

1:25

In this case, we did not see

1:27

anything in the cervical spine.

1:28

We did the axial scans.

1:30

Again, what is this tissue down here?

1:32

This is the temporal lobe

1:34

herniating downward across the tentorium to the level

1:38

of the pons and even to the internal auditory canal.

1:41

It's outrageous.

1:43

Patient has herniation of temporal lobe.

1:46

Here is the syrinx, the old syrinx.

1:49

However, when we went ahead and continued

1:51

to scan down into the thoracic spine,

1:55

and looked in a parasagittal location,

1:58

we found an area where the neural foramen was enlarged

2:03

and there was a big cyst in this neural foramen.

2:08

This ends up being the T9-10 level.

2:11

You can see contralateral side, not bad.

2:14

Let's look at the axial scans.

2:18

Axial scans still have that abnormal signal

2:20

in the spinal cord from the previous syrinx.

2:24

As we come down even further on T2-weighted imaging, you see this big cyst.

2:31

This cyst was the source of the leakage of

2:37

cerebrospinal fluid, leading to decreased

2:41

pressure intracranially, and that appearance of

2:44

a Chiari I malformation, which was actually

2:46

not from Chiari I malformation,

2:48

but from intracranial hypotension.

2:50

How do we know that this is the source of the leakage?

2:53

This patient underwent CSF aspiration and then

2:57

obliteration of this cyst with a fibrin clot,

3:03

and with the obliteration of the cyst,

3:05

the patient's headache went away, and the findings

3:10

intracranially with respect to the dural enhancement

3:14

improved.

3:15

The whole sagging thing didn't improve

3:18

automatically, but the first thing we saw was the

3:21

absence of the dural enhancement in the patient.

3:25

Tarlov cysts in the sacrum region may also

3:29

be a source of loss of pressure of the CSF,

3:33

and that may be another, uh, etiology for

3:38

intracranial hypotension. As I mentioned,

3:41

pseudo meningocele associated with previous surgery

3:45

may also be a source of the loss of the normal

3:48

regulatory intracranial, uh, pressure in the intraspinal

3:53

canal, which can lead to the intracranial hypotension.

3:57

Now, if you have a patient who has postural

4:01

headaches after a simple lumbar puncture

4:04

or myelogram, what we usually do will be an

4:07

epidural blood, uh, an epidural blood patch.

4:11

Which we inject usually in the lumbar region,

4:14

and that will seal the hole from your lumbar

4:16

puncture and lead to correction of the patient's

4:20

headache, and they usually feel better almost

4:23

immediately after you do the epidural blood patch.

4:27

In this case, this was not obviously

4:29

associated with any intervention by physicians.

4:32

This was a nerve root sleeve cyst that had perforated

4:36

and was leaking CSF, resulting in this patient

4:40

presenting with intracranial hypotension, which was

4:44

misdiagnosed initially as a Chiari I malformation.