Imaging in Idiopathic Intracranial Hypertension & Spontaneous Intracranial Hypotension

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Imaging in Idiopathic Intracranial Hypertension & Spontaneous Intracranial Hypotension

12 Aug, 1:30 PM

[Music] so good evening i welcome to the faculty talk conducted by ayarya kerala in association with metrics and towards this i welcome doctor mom doctor matthew secretary kerala area and dr remington coordinator and today the program is moderated by dr tara pradap head of the department lakeshore hospital kochi i welcome dr tara pradhan the faculty for the faculty talk the topic is imaging in idiopathic intracranial hypertension and hypotension and this is going to be delivered by dr vegas chauvin is consultant radiologist freitas institute of medical science and technology pro and drum party welcome dr vikas chawan thank you now over to dr for the introduction of the faculty so good evening all i welcome all of you to this faculty talk on imaging in intracranial hypertension and spontaneous intracranial hypertension by dr vikas chauhan dr vegas is pursuing his gm in neuro imaging and interventional radio neuroradiology at the prestigious street renal institute of medical sciences and technology dr vikas did his mbbs from afmc and his md from mumbai he has got several oral papers and presentations to his credit he has he presented an already paper on zero tmr imaging for evaluation of skull base and calvary relations he won the ge radio aspire quiz in 2021 he also won the independence day request conducted by ref cafe ranjin i welcome dr chauhan for his talk over to you dr vikas darwin uh thank you man for the kind words and introduction today i will be discussing imaging idiopathic interest in hypertension and spontaneous interact in hypertension and before i begin i would thank i would like to thank kerala ireland and all its faculty for providing me this opportunity so in my talk initially i will be showing few cases from our hospital and then we will be discussing the relevant imaging findings so before we begin we should understand the csf dynamics which happens in our brain we know that csf is produced in the lateral ventricles and it comes to the subarachnoid space through the foramen of lashka and magenta and in the subarachnoid space through the arachnoid granulations it absorbed into the neural venous sinuses and goes back into bloodstream and to understand all the features of hypotension and hypertension which happens in the brain we should understand the munro calorie doctrine which was propagated around two centuries back which states that as our kidney cavity is a rigid sphere and it is filled with capacity with non-compressible contents like brain deficiency csf and blood so if one content is increasing in the volume then the other content should decrease in pressure or volume to accommodate the changes and this division equation which says that intracranial csf pressure is equal to resistance to cs of r2 multiplied by csr formation plus pressure in the sagittal sinus and we know that the pressure in the superior central sinus ranges from three to ten millimeter of mercury and in conditions a physiological condition where there is jugular vein compression or in the pathological condition where the thermostat will jugular vein this pressure rises and subsequently it gave rise to interchangeable suppressor also so coming to the first part idiopathic intracranial hypertension initially i used to get confused between hypotension and hypertension features but if we study them together then it makes sense so pride men need all gave these criteria to diagnose this ih also known as pseudotumor cellulite in 2013. for this we need five features first of all practice then on examination of the patient neurologically there should be no abnormality except for the cranial nerve abnormalities neuroimaging should not repeat any secondary cause of increased intratechnical pressure like brain tumor meningitis cellulitis thrombosis hydrochemist on analysis of csf composition the csf study should be normal and opening pressure on the lumbar bunches should be high but these are the five criteria if all criteria are met but this lumbar puncture is not elevated then it's not a definite ih it is a probable ih also if we don't find paclidema clinically then we have to rely on the neural imaging findings or on sixth grade love policy so the surrogate masters for pakidema are either sixth grading of policy or three out of these four mri imaging criteria which are empty cellar flattening of the posterior aspect of the globe and distension of the perioptic surface is plus minus tortuosity and transverse venous sinus stenosis so keeping these points in mind we will be seeing our cases one by one coming to the case one she's a 26 year old female who had a history of headache for last five years headache is full style in nature he's on one side and it lasts for one hour and is associated with bombing there's no diplopia or tinnitus and there's no history of any supplementation of vitamin or indigenous drug intake or pcp intake she also gets history of weight gain of 5 kg in last month on neurological examination her cranial nerves are normal but on fundoscopy there is bilateral capillary pregnancy there are no signs of meningeal irritation csf opening pressure is high as we know the normal pressure is up to 180 millimeter of water but here it is to 90 but total count sugar protein and glucose were all within normal range on imaging we found that there is torsicity of the optic nerve c both horizontal as well as vertical torso which is seen by the spherical sign also there is distinction of perioptic nerve sleeves in this image we can also appreciate flattening of the posterior globe pilotry on surgical image of the midsection we find there is empty cellar c and there is mild inferior pegging of the tonsils on vinography which we appreciate bilateral transverse sinus strosses on the lateral aspects so this 26 year old female with headache for last five years with papillion and without any irregular deficits with high opening cs pressure so she is satisfying all these uh five criteria uh given by fragment and she clinically fits into ih and also or we have all the four findings which are seen on imaging for this criteria so she was started on established and she was told to be on regular follow-up and report to the hospital if any emergency office of symptoms occur the second case she is a 30 year old female who presented the history of discharged from right nostril for last two weeks and a month before that she also had persistent daily headache the headache was holopreneur dialectic with associate creators in both tears and visual learning there was no other neurological symptoms so when she had this lynoria her headache improved more than 50 on examination she was obese with bmi of 35 and there was a clear discharge from her right nostril neurological evolution showed early practitioner otherwise the examination was normal on this ct image we find there is a defect in the basic frontal bone on the right side entitled to reform plate and similarly our mr cesternography we find there is a css leakage with herniation of characteristics through this defect again partial empty cell could be appreciated and inferior there is perioptic sleeve prominency and threatening of the posterior lobe noted again on these images we could appreciate perioptic nerve shape prominence one mr vinography there is stenosis of bilateral left and right transfer sinus on the lateral aspect so see the case of ih which is leading to csf rhinovia as her opening pressure was 25 centimeter of water with normal composition so satisfying this uh two criteria she has pept edema and normal neurological examination and mri does not reveal any findings of uh venus sinus thrombosis meningitis or any tumor so again she was started on estrogenomite for six months and before that she was operated for this defect in the ancient portion she had some relief but again she developed severe edema and headache and again the lumbar puncture showed increased opening pressure of 30 centimeter of water so she was taken up for deficient and this gave her serious pressure and she became disrupted after surgery third case 46 year old female with dyslipidemia hypothyroidism presented with 13 years history of headache and it was holoclavial with severe intensity associated watering and redness of eyes it used to last for 15 days and she was headache free for the next 15 days then it recovered again she also had an event three years back associated confusion followed by right-sided headache and visual laws from which she will be covered in peace for defendants she has been evaluated in multiple centers and revealed multiple times mri brain css studies dsas missing botox max self super orbital nerve block but she got no lead in may 2021 mri brain shows features as to ih with hyper intense sleep defects in left transfer surname she was started on warfarin but later stopped as thrombosis worker was negative and mrb tested aeronautical on in june 2022 she had authentic evolution with normal physical activity and visual fields she continues to have headaches for having multiple medicines her case of poking pressure was normal and other css parameters was also normal in mri we find tamtiscella mild prongs of perioptic nerve sleeve only on the orbital part it measured around 6.2 millimeter no definite flattening would be observed in mri we see a filling defect in the left transfer sinus which appears like a rectangular regulation so she does not have capital edema and it was thought of probably initially and was optimized on acetonamide and as her cs of operating pressure was also normal after stopping dynams she was not fitting into these criteria given by fragment so absence of factory demand elevated and both were missing elevated of the pressure so this current simple project was not explained by edge but imaging towards some features of is so we should not allow we should not lie only on the imaging features but also give cognizance to these clinical features and other uh features described by frank men so in view of recurrent hemiparesis associated attacks of headache complicated migraine was a more likely possible fourth case is 51 years old female who presented history of multiple episodes of kittiness for the last one year which aggravated moment and associated with moderate to severe intensity of holocaust associated bombing there was no history of loss of consciousness seizures weakness visual disturbances sensitivity disturbances of our bladder bubble completes there was normal visual activity and there was no faculty now in downward nation of the circular tonsil peg shape and triangular and csf study was done which showed absence of the flow through the foramen magnum posteriorly stresses of the lateral aspect of the left lateral ventricle and on giving contrast there was no enhancement seen of the was absent so this 51 year old female presented the history of multiple episodes of willingness for last one year which aggregated with head movement and imaging revealed based intracranial attention science with suspicious stories of leg transfer sinus and hypoplastic right transfer sinus she was referred to her hospital for dsa and pressure sinus measurement across the sinus bs remained diffused narrowing off right transfer sinus and there was focal stresses of the left distal transfer sinus but on vs special gradient there was no significant venous pressure created across the portion of the transfer sign so again she had only empty cellar and mild distended perioptics of electron space she did not have flattening of posterior globe or transfer sinus process on venous pressure measurements and there was no papillary edema so she again did not fit into the diagnostic criteria for iits by admin and was uh treated as suspected carry one alpha machine the fifth case uh this is a 45 year old lady who presented with chronic headache for last 14 years duration she had pictures of raised icp and was evaluated elsewhere diagnosed to have ih216 and received estrogen for a year with complete revision for a headache for koreas in june 2020 she had a recurrence of addict and she underwent repeat mri and when she came here for evolution she was found to have bilateral being normal so on mri we find that cell is enlarged and empty there is perioptic now sleep from this and this is the 2016 mrb and this is the 220 mmrp in the 2016 mrp we find that and again in 2020 we find absence of flow in the posterior aspect of severe system sinus and bilateral transfer sinuses and with collateral uh realization of veins in the sky the dsl that again showed peeling defects in the transverse sinus and the posterior aspect of serious extra sinus so in this case imaging revealed a finding of secondary ih which is cerebral venous thrombosis so again this criteria will not apply uh for the diagnosis of ih and c is a case of secondary due to thrombosis of penis sinus so she was again started on esther jeromite along with metformin to aid in weight reduction and also in view of multiple collaterals in mrp euro ladyfista was suspected and was ruled out with bsa as the venus sinuses have recanalized and the last mri was more than seven months ago there is no indication to start on integration so again we have to know all these conditions which can mimic ih on imaging and we should not rush to make the imaging uh diagnosis ih uh before considering all these parameters which are given by clinical and csf pressure and csf composition analysis so these are the risk factors which are for ih the highly likely risk factors are female gender obesity endocrine disorders like addison's disease hypoparathyroidism destroyed withdrawal growth hormone used in children nutritional disorders like hyper vitamin c hyper elementation drugs like endomethacin uh toxin doxycycline etc are also provided risk factors these are possible risk factors and these are unlikely risk factors these are the recommended mri protocol in ih we have to do session t1 weighted image to rule out empty cellar to exclude for premium cervical junction where carrying malformation has to be pulled out exactly weighted images and flare images to rule out space occupying agent hydrocephalus and other pathologies which caused secondary traction in hypertension orbits fat saturated axial and coronal images to evolution for optic and optic nerve force or we can do a 3d cis to evaluate the same with additional information about flattening of the posterior aspects of globes intraocular protection of the optic nerves and enlargement of electronic species images are required to rule out meningitis abnormal enhancement of pathological processes venous sinus thrombosis and also c for optic nerve head enhancement also mr binographic off or post contrast mr genographic is related to rule or penis sinus thrombosis and narrowing of the transistors so this is the checklist for mr reporting and as i already told imaging science we have to first exclude major causes of secondary interacting hypertension and then look for typical imaging signs of ih and additionally we can assess additional findings which may present only in some cases like enlargement of vital scale beneficials within skull base prominent arachnoid variations css leaks platelet-like ventricles acquire tonsillar ectopia this paper came recently by maharashtra at all uh they evoluted quantitative parameters for the diagnosis of ih they studied optician uh diabetes which usually heightens fat thickness and they found that optic nerve diameter on mri correlates with lumbar pressure particular opening pressure and there is significant difference in object now diameter on mri between ih patient and control patients roc analysis showed high accuracy of optic nerve diverted in differentiation between ih and control and they gave a cutoff of 5.4 millimeter with high sensitivity of 77 and a specificity of 85 which represented high accuracy in this study by srikant boruto at all they studied the pressure variations in several venous sinuses for ih patients and they found that the pressure in superior sinus transfer sinus and sigmoid sinus varied considerably between three and post entity and there was at least eight millimeter fall in the pressure in superior system and transfer sinus and conversely about eight millimeter increase in the pressure of straight sinus this was immediate posting measurement but if we follow the patient on it to after two or three months this pressure of this straight sinus is also normalized again the transgenetic gradient pre-standing was high of 17 and it turned and all systolic diastolic and mean pressure variations in the transfer sinuses had reduced after stenting now you come to the second part which is spontaneous interacting with hypotension first case she is a 57 year old female with no associated comorbidities she had a headache from the age of 25 years which was bilateral pulsar type type of headache reaching peak within three hours lasting for around four to six hours associated with photophobia and phonophobia also with vomiting and it was lead by lying down there was around seven to eight headaches per year she did not seek any treatment because she was tolerating them later for last six seven years the headache has become more frequent almost occurring daily lasting entire day and not only by medication or vomiting it has become holo cranial extending up to the name of neck and was exaggerated by changing the posture becoming severe on trying to get up from spine position like sitting standing even at times disturbing sleep it increased on coughing there was no early morning headache there was no diplopia there was no history of visual observation there was no gate disturbance or weakness of these so on imaging on ct axon images we find the bilateral subtropium hydromas with few membranes of hemorrhage also and outside mri and we second enhancing smooth enhancing of packy messages and involves sinuses and pituitary engagement a mating which was done in our hospital shows a finding of slumping of the brainstem structures uh in god's pituitary concentrating and this perioptic now sleep was not seen at all so in midline sagittal images we can appreciate that the item which is the entry point of the server attribute is normally placed within one millimeter of this institutional line which is drawn from the tuberculum to the junction of so in this it has moved to around eight millimeter that means the brain has sat downwards the quantum essentially angle which is less than which is more than 50 it has become reduced to 31 degrees we see this mammary body and pawns onto primary distance has also been reduced less than 5 in this case and there is also downward consular herniation seen the splenium appears droopy and this is the normal point of the sensitivity angle and this is the normal uh quantum memory distance for comparison you can easily make out the difference between the two so this paper by looked for manual content distance which were quite different in control as compared to patient with ih uh i uh sorry interchange hypotension and quantum mechanically angle of 50 degree in control and less than that in patient with hypotension other features we found in the patient was bilateral subdural hygromas with hyper intensity on flare and t1 as resistive of bleed within and co kind of blooming within the collection system of the conversion of into hematomas similar features appreciated on t2 images and in this image we find that the shape of midbrain is distorted it is long anterior and in this image bilateral ambient systems are efficient and we are not able to make out the shape of the pinplane so this is called sagging of the mid brain and a paper of neurosurgery has objectively defined the sagging by a sag ratio in which it anti-posterior diameter you can calculate a ratio and you can quantitatively assist the patient before and after the intervention how the site has reduced again on t2 corner images we appreciate bilateral subdued collections and engaged pituitary and also uh collections extending along the temporal membranes on t2 sets size images of the spine we see there are epidural collections which are also known as selects final longitudinal epidural collections seen both anterior and posteriorly similarly on this image on cis images again these the dura is seen more clearly and these collections are appreciated better these collections are also extended to the lower thoracic and number spine and in our study we found this csf out watching at on the left side at c1 c2 level which we thought was the cause of css leak and then the dural defect was found at c1 c2 level this was displayed in neurosurgeon and application of epidural patch was advised and sdh management was left this patient becomes symptomatic and that after if that patch was instantly neuro anesthesia guidance procedure was uneventful but a lot of caution there may be a false localizing sign at c1 c2 level uh which has been described in this paper in 2004 by chevy because as the collection in epidural space travel upwards when the patient is lying down at c1 c2 level there is the momentum flavor has produced yellow fat and the epidural fat is less there are also increased lymphatics in this area so the epidural fluid collection easily goes and settles in this place and on mr systenography or myelography we find that this space to be bright containing csm so this may be a fast localizing sign and we have to be aware of that similarly again schemnek after 10 years in 2015 uh came out with this paper on another files localizing the region at the level of cervical thoracic level so treatment directed at this site should not be expected to have a high probability of sustained improvement of system symptoms coming to the second case she is a 61 year old female with history of headaches as of migraine for the past 45 years now presented to the history of changing character of attack for last three weeks in form of precipitation on sitting position and live with the recombinant portion without any visual cranial vulva or motor or sensory systems examination patient was conscious and oriented higher mental functions were normal condensed examination was also normal the cranial nerves were wrong what a sensory circular examination of normal weight was common the possibility considering view of personal images on post contrast even excel images there is smooth frequent enhancement of packing manual scene because duran lacks the broadband area there is enhancement of the packing in this and because this enhancement is not seen in the laptop energies and electromagnetism enhancements again on t2 excel we find that the placement of immune system but the morphology of midbrain is needed on most contrast size image there is a prominence of the venous sinuses scene with twitter engagement in c and mild decrease in quantum is sensitive angle and inferior construct descent is noted again we cannot appreciate any perioptic sleep which is normally seen in ih in this excise case and the globes are rounded perfectly under the posterior aspect can be seen on again thick smooth enhancement of packing manager scene with on flare there is bilateral suburb collection and this collection at faces rooms such as hemorrhage within the collection amarvinography again shows rounding of the transverse sinus on sagittal images prominence of the space central sinus and almost all venous sinus are apparently prominent and again if we don't have a marginography this white image with thick mid can act as a surrogate which can show us the prominence of the venus sinuses on post contrast t1 threat set said we can appreciate the enhancing equatorial venus plexus and again this epidural collections which are due to csf or due to the venus engagement with dura scene on the both sides of this csf again on mr milography with heavily distributed sequence on left side at 9 p10 level we could appreciate a prominent csl collection and we put an epidural patch at this level and patient already did the procedure well and specially there was no complication except for my nuclear pain and there was significant reduction in the headache so this probable site of csf was indeed the site of league but it is not very easy and we were lucky to get the results otherwise it's very hard to chase or find out the sight of exactly so coming to the discussion spontaneous intracranial hypotension is an under diagnosed disease and awareness of this condition will lead to increasing diagnosis about five percent per lag per year is the incidence and again it's more common in females the most common symptom is positionally dependent headache which worsens on standing position and tends to increase in severity over the course of pain the positional dependence of headache more launched on the back of it is due to the dura mater of the posterior fossa being more sensitive to tension and sagging of the brain impinges on the posterior part and the patient may exactly recall the day when it called deeply so it's not the patient like when the leak happens the pain happens on that day itself and the patient may recall that exactly these are the vagus uh types of csf leads which has been described type 1 is the dural leak due to some osteophytes of the disc in the anterior aspect which tears the tula and it is a ventral leak sometimes it could be a dorsal leaf by the calculated ligament titan 2 is a meningeal diabetic which happens in the axilla of the nerve root again it could be simple or complex type 3 is the csr venus fish flap and it is a rare type of leakage in which we will not find the evidence of sled on spinal imaging there will be no epidural collections seen in the spine mri and a clinical suspicion and failed epidural patches may lead us to do more investigation and product across this condition and type 4 are interpreted or unknown or where there is epidural venous drainage which is seen much less frequently there are other causes of sih like medial sphenoid cannibal cells or connective tissue disorders or post surgery or trauma in patients who have been suffering from issues for longer periods the headache can lose their positional dependence or even worsen when the patient reclines so the opposite happens normally initially for first three weeks the positional dependence when the patient gets up from lying position the headache increases but later it can reverse and patients also complain of audited disturbances like fullness of ear ringing or tinnitus and may be treated as assent or menial disease and rarely can have very severe complications like comma or frontal temporal dimension this is a diagnostic criteria by international classification of it shows that orthostatic headache of spontaneous onset that is due to low css pressure or csse and accompanied by nuclear pain enactus audited disturbances homophobia nausea and remission of symptoms after normalization of csa pressure or closure of csfd so these are the diagnostic criteria temporal relation to low pressure and then low pressure on measurement but we have to keep in mind that low csi pressure of less than 60 is only seen in one third of the thesis and there should be no other diagnosis which is more suitable so these are the various legal manifestation the main orthostatic headaches in up to eighty percent of application uh disturbances relate to two years in approximately 50 percent of the patient one-fifth of the patient may present with nausea vomiting photophobia science like and other 50 percent can have position independent thunderclap on existing on coffee headache which that's worsening off lying down so exactly opposite of authority headache others like real which happens in this patient can cause sensory neurone hearing loss attaching and dementia and see in one tenth of the patient galactoria hypochlorous can also happen because of hyperemia pituitary so this paper by our institute which came up in 2012 relates all these clinical features with the etiopathy imaging coordinates and helps us in understanding uh why patient is having these simple features and one thing to be aware of sih is that csf loss always happens in the spine usually due to ventral vertical neural tear or a laterally located nerve through diverticulum or rarely 10 percent of the cases into cs3 only one third of the patient will have low open pressure and in patients who are obese the opening pressure can be high also and there is no single test which can reliably diagnose this condition so we have to be very methodical and choose our test wisely values so this is the diagnostic and therapeutic algorithm for the sih this is the type of diagnostic study and what is the goal and what are the pathological findings had mri for demonstration of sig science and potential complications spinal mri for demonstration of epidural fluid and meningeal diverticular csf pressure management to know what is the opening pressure and sometimes csf infusion test will be more reliable and we can know the css outflow resistance dynamic myelography is needed to demonstrate csfd in the epidural space milo ct also demonstrate epidural contrast medium dynamic ct sometimes can use be used to precisely localize the csf key when epidural patches fail and we are planning for surgery because if we know the exact site only then only can be done while epidural blood patch can be given blindly and also dynamics subtraction myography can be done to demonstrate the rare cause of csf venus when the spinal imaging does not show any epidural collections or diabetes again the therapeutic algorithm initially will try conservative management of addressed hydration caffeine then the equivalent blood patch which can be under fluoroscopy city guidance possibly multiple blood patches initially started around 20 ml of blood then later going up to 8200 ml surgery only if the site of leak has been precisely localized and epidural blood prices have failed or the patient is having rapid progression of brain herniation and as a life saving procedure so these are the few techniques which help us to find the csfe in dynamic myography in tone or lateral distribution a bolus of contrast medium is introduced in subordinate space to lb needle patient is put at prone first and the head of the table is then lowered while lateral fluoroscopic imaging on the back is performed the goal is to visualize the contrast medium as it runs in the trailer direction on the ventral side of the surface final mri around the suspension of csf draws from managing this structure is performed as position with horizontal is subsequently performed to determine whether any contrast medium lies in the articular space and if so then at what level after fluoroscopy we do myocity dynamic myelocity is also reserved in few conditions where we are not able to localize the site and it is also known as ultrafast dynamic ct scanning is performed in alternative direction in right and left lateral just during and immediately after contrast medium injection the patient can be elevated on a foam wedge and this study has delivers a large decision goes to patient so we should not perform it without the patients have undergone other measures so this is the central reformative image for ultra pass dynamic city and in the initial imaging phase the contrast is seen in the uh subarachnoid space and there is a spur of the osteophyte which is seen impinging on the dura and in the next second equation the some arachnoid space contrast has progressed cephalic and from this tier it has leaked into the equatorial space a digital uh dynamic distance subtraction myography in this technique uh we use patient on dsa machine and the patient is thrown a question prone or lateral depending on what we are suspecting and initially before injecting contrast vp pressurize the theta was the line to increase leaking and images are required at one to two frames per second with infusion of contrast media at one ml per second followed by saline changes imaging occurs during suspended respiration to avoid motion artifacts and up to 70 seconds long accusation may be required so it's better to take patients as a patient cannot breath hold or lie still for 70 seconds so this test is reserved for patient whose symptoms history and test finding implies probable sh but whose myocity does not reveal any contrast medium in cases when we are suspecting so for css venus this dynamic tsa myography is good and this lateral position prone digital subtraction diagram shows contrast medium line dependently in the thoracic suburban space and leaking through this dual tier at t4 t5 levels in mental attitude collection again uh another image for dynamic uh distance substitution milography which is showing a diabetic plume which is opacifying the draining paraspinal veins and generally we target the thoracic area because it is the most common site for leak and as our detector size is limited so we have to target the most all area so coming through the treatment first we try conservative management if it fails we go to a product patch or catch and this can be done without any imaging or with uh fluoroscopic guidance and the administration physician detects the penetration into the space as a loss of resistance to the passage of neutral right after the tip has crossed the limit and immediately after the blood patch patient gets the lead there are two theories one is back theory which says that the blood blocks the lead side but it is very unlikely because once the leak is plugged the csr production is at a rate of 0.5 ml per minute and around 200 ml of csr is deficient so it may uh need around 400 minutes for the csf to get collected so another pressure theory is that when we put blood in the actual space the uh subarachnoid space of the spinal cord rights and the csf is pushed up into the cradle cavity and the vibrancy of the creamy cavity returns and the patient feels relief operative closure of spinal cord is indicated if the symptom persist despite less invasive treatment measures and its spinal cord has been definitely localized so failure of bacterial blood patch and exact localization of css previously needed at certain the leak can be close microscopically with simple switching or with an adjacent patch of the dura mater with the current neurosurgical methods nerve group diverticula died csv and laterally and ventricularly rotated ears can be reached through a dorsal approach and [Music] so nowadays no need for mental approach only through torso approach also only we can keep this surgically this is fluoroscopic guiding application of the breath and when the gps feeling is there then we inject a tense dose of contrast and see how the contrast is spreading and it should not be into the subarachnoid speech it should be in the epidural space and after a injecting blood which has been withdrawn from the forearm of the patient around 20 mm we see how the blood is uh varying if the patient has pain or sheath of the stop and we try the question again after some time the most prominent clinical manifestation of spontaneous intraocular hypotension is orthostatic headache many patients also complain of auditory disturbances the longer the disease has been present the less potential positionally dependent in the headache becomes only one third of the patient have low obtained csr pressure less than 60 millimeter of water and the key diagnostic finding is the glass of csf from the spinal circular space into the technical space which can be seen on various imaging modalities factorial blood pressures applied under the fluoroscopy or cd guidance under 30 to 70 percent of sih patient asymptomatic ventricular peers usually need surgery because there is a spur which is increasing on the tf and this uh till the time the spur is removed out of the device it will not bleed at present all type of series history can be closed with a minimal invasive procedure performed through a dorsal approach and the substances rate of operator closer is more than 95 percent so these are the recommended mri brain spine protocols for sh mainly we have to rely on 3d heavily weighted q2 sequences apart from routine sequences and post contrast even weighted images to see the enhancement of images uh packing images again on spine we have to do d2's pattern images to look for the epidural venous sinuses or fluid collections and diabetes or can we see in on 3d heavily two weighted steady sequences and we also need circuit and axial force which contrasts weighted images enhancement and these are the checklists for reporting initially we have to assess them between location on suggestion view or possibly quarter brain displacement or brainstorm setting assess the subdural spaces for any subdued collection of families check if there are signs of venus in the government if we look at the seller region for petite gland enlightenment and subtracting of the optical look for dural thickening and enhancement after contrast administration assess the spinal canal for ambiguous fluid collections in large actual means durable enhancement or extracted equal season collections again this paper compares various imaging tests for detecting and correcting csf keys and initially study the choices ct milography or conventional mri it will have ability to created mris um distal substances myelography and dynamic ultraviolet myography have got a lot of radiation those especially fast dynamic myography so it should be reserved only for problem solving cases and sometimes but not nowadays use is nucleotide study which can detect slow flow leaks for fast flow leaks we have to uh undergo ultra fast ct myography or distance subtraction myograph and uh for uh csf venus fishball also distance obstruction biography this is the example of a normal patient and a patient with csf lead or indium atpa radionuclide systemography in normal patient there is no activity seen in the kidney or bladder upto 5 hours and there is the activity reaches the basal system in 5 hours at the several convexity and 24 hours if there is leak the site of need can be seen as early as one hour and there will be activity seen in the bladder and kidneys by one to two hours and there will be no activity in the csf convexities at 24 hours and there will be washout to the activity from the spine relatively fast so this is a very complicated workout for the patient in the sih case so we should go step by step and this is our suggested algorithm for investigation and management the choice of imaging techniques will depend on the overall operator experience with friends and resources so if we have a suspicion we have to initiate contrast without any side to patient of radiation dose if the patient is persistent uh symptoms are not cured and there is also this epidural correction which is seen then whether it's mental or circumstantial we have to milography or dynamic circulation microgravity if leaked cycle is located then we can go for targeted predicting or surgery if not then we have to again do some investigation of myography to localize if this mri brain is fine looks normal but there is strong blinker suspicion again we can go for epidural red patch now it will be called diagnostic factor patch if it shows improvement then we can suspect this fishblock and again if the patient recurs these symptoms we can undergo he can go for this basic procedure if there is no response to diagnostic blood patch also and the mri brain and spine is normal then we have to consider other causes to be executed for alternate diagnosis so another article which came in 2019 which gave a scoring system whether it is a definite or probable so they gave major criteria two points each and minus criteria one point each major criteria in a sinus involvement during enhancement and superpower of less than four million this happens because of pituitary engagement between land becomes superior convex and supercraft system is defaced minor criteria is subdued fluid collections free quantized system less than five millimeter and manual contact distance less than 6.5 meters six point here and three point here so out of nine points uh this score less than two or two is low probability three to four is intermediate probability and if you are getting five or more then it's a high probability so almost finished there are few uh images which i want to show before i wind up this image of a normal question shows how normal transistor sinus has anterior concavity but in acids this is anterior convexity and grounded bulging image is seen normal patient have this straight sinus it is thin but it gets involved in this edge again this is a sis case and this is carry one both have got inherent constant displacement but in sih we find other features of sights like sagging of the midbrain decreased magneto content distance etcetera very carry one this is not there mangalore content distance is maintained quantum mission sufficient angle is normal and three quantized systems are not increased these three patients one is sih middle one is normal and this is i aged now you just see at the perioptic nerve sleeve thickness in iih it is increased in normal patient you can just visualize it but in a size case you are not able to see any of the perioptic nerve sleeves so this sign can also be helpful again rarely you can see layer cake hyperostosis and this appearance can be there again due to hemocytosis repeated hemorrhage there can be superficial process of the dura and also of the uh cerebellar one piece so we should also look for these signs thank you thank you so much it was such a wonderful and fantastic presentation and you are such a wonderful teacher like the layout of the presentation the discussion the dvds the algorithms are indeed wonderful and i am sure that bds have benefited a lot from your presentation i think they need to listen to it again and again because we have enumerated a lot of points in a short span of time just to know if there are any questions in the chat box uh somebody from the netflix team are there any questions uh no ma'am there are no questions uh there are no questions now okay so i think everybody has understood it so well and dr chaven one question from my side like uh you said about the ultra fast ct so do you need a special equipment for that or can we do it on our ordinary machines well you can do it on ordering machine but the special equipment which we need is a very foam shape which makes the patient like in reverse uh like renewable position so that contrast after injecting can migrate downwards so we need any special add-ons to our existing machines okay okay and um sir if you could please uh stop screen sharing it would be great so that i can and regarding the black patch technique like we have done a couple of uh black touch techniques in our institute but then like you know we always used to choose the cervical approach but then um is it okay like you know if you do it at the lumbar level as well because the leaks are seen at lower cervical thoracic or lower thoracic levels so um injecting the blood uh because the lower uh torso and upper lumbar levels have got enough space so injecting will be easier and when we put patient in reverse position the back migrates upward so better to do in lower thoracic or [Music] because they have got high rotation dynamic dsi is preferred only if it becomes negative on ct right uh the criteria for that is high failed epidural patches and all mr of the spine we are not getting this longitudinal collection that means uh there is a component of csf europe fish plant neural venus fish flow uh i think spontaneous intracranial hypotension is not very uncommon and we often come across in a clinical practice so i think um like we have really enlightened us on this topic and i think if there are no questions we can wind up the session thank you so much for taking your time off and being with us and for accepting the invitation wholeheartedly somebody from the i and i thank dr bijay for all the support rented and uh i i thank the netflix team for the support technical support offered and i think doctor venus would not log in so he missed since i thank everyone who has attended this session the pts and all the other audience and consultants so once again i thank you all and i declare the session closed thank you so much once again


Join us for a very interesting discsussion on Imaging in Idiopathic Intracranial Hypertension & Spontaneous Intracranial Hypotension with Dr. Vikas Chauhan. This session is part of 'IRIA Kerala Academics Faculty Talk'. Join us live on 12th of Aug at 7.00 PM live only on Medflix.


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