Advertisement

Post-dural puncture pseudomeningocele (“arachnoid bleb”): An underrecognized etiology of spontaneous intracranial hypotension symptomatology

Published:September 06, 2021DOI:https://doi.org/10.1016/j.clinimag.2021.08.023

      Highlights

      • PDPH is a well-known and common complication of dural puncture/neuraxial anesthesia, with a reported incidence of 10-40%.
      • While PDPH typically remits spontaneously or with autologous EBP, chronic cases can become complex and difficult to manage.
      • We present a case of a post-dural puncture arachnoid bleb resulting in SIH, treated with curative surgical intervention.
      • Increasing awareness of etiologies of SIH allows for improved detection for definitive treatment and improved outcomes.

      Abstract

      Spontaneous intracranial hypotension (SIH) is an important secondary cause of a persistent headache syndrome, classically presenting as sudden onset debilitating positional headaches related to reduced intracranial cerebrospinal fluid (CSF) volume. Current understanding of SIH pathogenesis recognizes three underlying etiologies: dural tear, meningeal diverticulum, and CSF-venous fistula, with a fourth broad category of indeterminate/unknown etiologies. Post-dural puncture headache (PDPH) is a well-known and common complication of dural puncture, typically remitting spontaneously within two weeks of onset or with autologous epidural blood patch, though with some patients developing complex and difficult to manage chronic PDPH. Herein, we present a case of chronic PDPH resulting in SIH symptomatology secondary to a post-dural puncture pseudomeningocele, or “arachnoid bleb,” successfully treated with curative surgical intervention. Increasing awareness of additional potential etiologies of SIH symptomatology will allow for improved detection for targeted definitive therapy, ultimately improving patient outcomes including quality of life in this debilitating and difficult to manage secondary headache syndrome.

      Abbreviations:

      CSF (cerebrospinal fluid), CVF (CSF-venous fistula), PDPH (post-dural puncture headache), SIH (spontaneous intracranial hypotension)

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Imaging
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kranz P.G.
        • Malinzak M.D.
        • Amrhein T.J.
        • Gray L.
        Update on the diagnosis and treatment of spontaneous intracranial hypotension.
        Curr Pain Headache Rep. 2017; 21: 1-8https://doi.org/10.1007/s11916-017-0639-3
        • Kranz P.G.
        • Gray L.
        • Amrhein T.J.
        Spontaneous intracranial hypotension: 10 myths and misperceptions.
        Headache. 2018; 58: 948-959https://doi.org/10.1111/head.13328
        • Madhavan A.A.
        • Kim D.K.
        • Brinjikji W.
        • Atkinson J.
        • Carr C.M.
        Diagnosis of a cerebrospinal fluid-venous fistula associated with a venous malformation using digital subtraction and computed tomography myelography.
        World Neurosurg. 2020; 135: 262-266https://doi.org/10.1016/j.wneu.2019.12.075
        • Olesen J.
        Headache classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders. 3rd edition. Cephalalgia. 38. 2018: 1-211https://doi.org/10.1177/0333102417738202
        • Gaiser R.R.
        Postdural puncture headache: an evidence-based approach.
        Anesthesiol Clin. 2017; 35: 157-167https://doi.org/10.1016/j.anclin.2016.09.013
        • Weji B.G.
        • Obsa M.S.
        • Melese K.G.
        • Azeze G.A.
        Incidence and risk factors of postdural puncture headache: prospective cohort study design.
        Perioper Med. 2020; 9: 1-6https://doi.org/10.1186/s13741-020-00164-2
        • Schievink W.I.
        • Maya M.M.
        • Moser F.G.
        Digital subtraction myelography in the investigation of post–dural puncture headache in 27 patients: technical note.
        J Neurosurg Spine. 2017; 26: 760-764https://doi.org/10.3171/2016.11.SPINE16968.760
        • Kranz P.G.
        • Luetmer P.H.
        • Diehn F.E.
        • Amrhein T.J.
        • Tanpitukpongse T.P.
        • Gray L.
        Myelographic techniques for the detection of spinal CSF leaks in spontaneous intracranial hypotension.
        Am J Roentgenol. 2016; 206: 8-19https://doi.org/10.2214/AJR.15.14884
        • Kranz P.G.
        • Tanpitukpongse T.P.
        • Choudhury K.R.
        • Amrhein T.J.
        • Gray L.
        Imaging signs in spontaneous intracranial hypotension: prevalence and relationship to CSF pressure.
        Am J Neuroradiol. 2016; 37: 1374-1378https://doi.org/10.3174/ajnr.A4689
        • Roytman M.
        • Salama G.
        • Robbins M.S.
        • Chazen J.L.
        CSF-venous fistula.
        Curr Pain Headache Rep. 2021; : 25https://doi.org/10.1007/s11916-020-00921-4
        • Kranz P.G.
        • Tanpitukpongse T.P.
        • Choudhury K.R.
        • Amrhein T.J.
        • Gray L.
        How common is normal cerebrospinal fluid pressure in spontaneous intracranial hypotension?.
        Cephalalgia. 2016; 36: 1209-1217https://doi.org/10.1177/0333102415623071
        • Schievink W.I.
        • Maya M.M.
        • Jean-Pierre S.
        • Nuño M.
        • Prasad R.S.
        • Moser F.G.
        A classification system of spontaneous spinal CSF leaks.
        Neurology. 2016; 87: 673-679https://doi.org/10.1212/WNL.0000000000002986
        • Farb R.I.
        • Nicholson P.J.
        • Peng P.W.
        • Massicotte E.M.
        • Lay C.
        • Krings T.
        • et al.
        Spontaneous intracranial hypotension: a systematic imaging approach for CSF leak localization and management based on MRI and digital subtraction myelography.
        Am J Neuroradiol. 2019; 40: 745-753https://doi.org/10.3174/ajnr.A6016
        • Luetmer P.H.
        • Schwartz K.M.
        • Eckel L.J.
        • Hunt C.H.
        • Carter R.E.
        • Diehn F.E.
        When should i do dynamic CT myelography? Predicting fast spinal CSF leaks in patients with spontaneous intracranial hypotension.
        Am J Neuroradiol. 2012; 33: 690-694https://doi.org/10.3174/ajnr.A2849
        • Beck J.
        • Ulrich C.T.
        • Fung C.
        • Fichtner J.
        • Seidel K.
        • Fiechter M.
        • et al.
        Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension.
        Neurology. 2016; 87: 1220-1226https://doi.org/10.1212/WNL.0000000000003122
        • Schievink W.I.
        • Maya M.M.
        • Moser F.G.
        • Tuchman A.
        • Cruz R.B.
        • Farb R.I.
        • et al.
        Spontaneous spinal CSF–venous fistulas associated with venous/venolymphatic vascular malformations: report of 3 cases.
        J Neurosurg Spine. 2020; 32: 305-310https://doi.org/10.3171/2019.8.SPINE19716
        • Kranz P.G.
        • Stinnett S.S.
        • Huang K.T.
        • Gray L.
        Spinal meningeal diverticula in spontaneous intracranial hypotension: analysis of prevalence and myelographic appearance.
        Am J Neuroradiol. 2013; 34: 1284-1289https://doi.org/10.3174/ajnr.A3359
        • Kranz P.G.
        • Amrhein T.J.
        • Gray L.
        CSF venous fistulas in spontaneous intracranial hypotension: imaging characteristics on dynamic and CT myelography.
        Am J Roentgenol. 2017; 209: 1360-1366https://doi.org/10.2214/AJR.17.18351
        • Kumar N.
        • Neidert N.B.
        • Diehn F.E.
        • Campeau N.G.
        • Morris J.M.
        • Bjarnason H.
        A novel etiology for craniospinal hypovolemia: a case of inferior vena cava obstruction.
        J Neurosurg Spine. 2018; 29: 452-455https://doi.org/10.3171/2018.2.SPINE171373
        • Lin S.F.
        • Weng H.Y.
        Postural headaches due to cerebrospinal fluid leakage through subarachnoid-pleural fistula: a case report.
        Headache. 2017; 57: 467-471https://doi.org/10.1111/head.12974
        • Hawk M.W.
        • Kim K.D.
        Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas.
        Neurosurg Focus. 2000; 9: 1-8https://doi.org/10.3171/foc.2000.9.1.5
        • Cornman-Homonoff J.
        • Schweitzer A.
        • Chazen J.L.
        CT-guided epidural blood patch for treatment of CSF leak and pseudomeningocele following tethered cord release in a 3-year-old.
        Clin Imaging. 2016; 40: 1191-1194https://doi.org/10.1016/j.clinimag.2016.08.010
        • Chazen J.L.
        • Robbins M.S.
        • Strauss S.B.
        • Schweitzer A.D.
        • Greenfield J.P.
        MR myelography for the detection of CSF-venous fistulas.
        AJNR Am J Neuroradiol. 2020; 41: 938-940https://doi.org/10.3174/ajnr.A6521
        • Kim D.K.
        • Brinjikji W.
        • Morris P.P.
        • Diehn F.E.
        • Lehman V.T.
        • Liebo G.B.
        • et al.
        Lateral decubitus digital subtraction myelography: tips, tricks, and pitfalls.
        Am J Neuroradiol. 2020; 41: 21-28https://doi.org/10.3174/ajnr.A6368
        • Patel D.M.
        • Weinberg B.D.
        • Hoch M.J.
        CT myelography: clinical indications and imaging findings.
        Radiographics. 2020; 40: 470-484https://doi.org/10.1148/rg.2020190135
        • Hoxworth J.M.
        • Trentman T.L.
        • Kotsenas A.L.
        • Thielen K.R.
        • Nelson K.D.
        • Dodick D.W.
        The role of digital subtraction myelography in the diagnosis and localization of spontaneous spinal CSF leaks.
        Am J Roentgenol. 2012; 199: 649-653https://doi.org/10.2214/AJR.11.8238
        • Amsler P.
        • Laing R.J.C.
        • Marcus R.
        • Booth S.
        Pseudo-meningocele following apparently uncomplicated lumbar puncture - a common procedure with a rare complication [3].
        J Pain Symptom Manag. 2003; 24: 363-365https://doi.org/10.1016/S0885-3924(02)00510-9
        • Hurlburt L.
        • Lay C.
        • Fehlings M.G.
        • Carvalho J.C.A.
        Postpartum workup of postdural puncture headache leads to diagnosis and surgical treatment of thoracic pseudomeningocele: a case report.
        Can J Anesth. 2013; 60: 294-298https://doi.org/10.1007/s12630-012-9846-x