SPONTAN İNTRAKRANİYAL HİPOTANSİYON

Öz

Amaç: Spontan intrakraniyal hipotansiyon dural yırtığa bağlı ortaya çıkan beyin omurilik sıvısı kaçağının neden olduğu klinik tablodur. Bu çalışmada, spontan intrakraniyal hipotansiyonun epidemiyoloji, patofizyoloji, tanı, tedavi ve prognozuna ilişkin bilgilerin gözden geçirilmesi amaçlanmıştır.

Gereç ve Yöntem: Hastalığın tahmini insidansı 2-5/100.000 olup, dördüncü dekadda sıklık artmaktadır. Kadınlar erkeklerden daha çok etkilenir ve altta yatan konnektif doku hastalığına eşlik eden mekanik olaylar beyin omurilik sıvısı kaçağına yol açabilir.

Bulgular: Tipik klinik bulgusu postüral baş ağrısıdır. MRG'de pakimeningeal kontrast tutulumu, venöz yapılarda konjesyon, subdural effüzyon-kanama, hipofizde hiperemi, beyin dokusunun aşağı doğru yer değiştirmesi kardinal bulgulardır. Spinal göllenmenin lokalizasyonunu saptamada radyonüklid sisternografi, BT-miyelografi, MR-miyelografi kullanılır. Tedavi, sırasıyla konservatif yöntemler (mutlak yatak istirahatı), epidural kan yaması ve cerrahi yöntemlerden oluşmaktadır.

Sonuç: Spontan intrakraniyal hipotansiyon, son yıllarda giderek artan sayıda bildirilen, tanısı geciktiğinde ciddi nörolojik komplikasyonlara yol açan, erken tanı ve tedavi ile geri dönüşümlü olabilen bir klinik tablodur.

Anahtar Kelimeler

• spontan intrakraniyal hipotansiyon
• Manyetik rezonans görüntüleme
• postüral baş ağrısı
• sisternografi
• myelografi

SPONTANEOUS INTRACRANIAL HYPOTENSION

Öz

Objective: Spontaneous intracranial hypotension is caused by spontaneous spinal cerebrospinal fluid leaks due to dural tear. In this study, epidemiology, pathophysiology, diagnosis, treatment and prognosis of spontaneous intracranial hypotension are summarized.

Matherials and Methods: The incidence has been estimated at 2-5/100.000 with a peak in fourth decade. Women are affected more commonly than men. Mechanical factors combined with an underlying connective tissue disorder cause cerebrospinal fluid leaks.

Results: The typical clinical finding is the postural headache. The cardinal findings of magnetic resonance imaging include enhancement of the pachymeninges, engorgement of venous structures, subdural effusion-hematome, pituitary hyperemia and sagging of the brain. Radionuclide systernography, CT myelography, MR-myelography are the studies to investigate the spinal cerebrospinal fluid leak. Treatments include conservative (total bed rest), epidural blood patching and surgical treatment of cerebrospinal fluid leak. The increasing number of patients are diagnosed with spontaneous intracranial hypotension recently which is reversible if treated early while delayed diagnosis may cause serious neurological complications.

Anahtar Kelimeler

• spontaneous intracranial hypotension
• magnetic resonance imaging
• postural headache
• systernography
• myelography

Kaynakça

1. Albayram S, Asik M, Hasiloglu ZI, Dikici AS, Erdemli HE, Altintas A. Pathological contrast enhancement of the oculomotor and trigeminal nerves caused by intracranial hypotension syndrome. Headache. 2011; 51:804-8.
2. Altınkaya N, Yıldırım T, Yerdelen D, Karakurum B, Yapar AF, Alkan O. Primer ve sekonder İH: klinik izlem, MRG ve radyoizotop sisternografi bulguları. Turk Norol Derg 2010;16.78-85.
3. Chen HH, Huang CI, Hseu SS, Lirng JF. . Bilateral subdural hematomas caused by spontaneous intracranial hypotension. J Chin Med Assoc. 2008; 71:147-51.
4. Cho KI, Moon HS, Jeon HJ, Park K, Kong DS. Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch. Neurology. 2011;76:1139-44.
5. Christoforidis GA, Mehta BA, Landi JL, Czarnecki EJ, Piaskowski RA. Spontaneous intracranial hypotension: report of four cases and review of the literature. Neuroradiology. 1998; 40:636-43.
6. Couch JR. Spontaneous Spontaneous intracranial hypotension: the syndrome and its complications. Curr Treat Options Neurol. 2008; 10:3-11.
7. Evan RW, mokri B. Spontaneous intracranial hypotension resulting in coma. Headache 2002; 42: 159-1
8. Ferrante E, Riva M, Gatti A, Brioschi AM, Guccione A, Colombo N, Vanini M, Veronese S. Intracranial hypotension syndrome: neuroimaging in five spontaneous cases and etiopathogenetic correlations. Clin Neurol Neurosurg. 1998; 100:33

9. Frank LR, Paxson A, Brake J. Spontaneous intracranial hypotension--a case report. J Emerg Med. 2005 May;28:427-30.
10. Gordon N. Spontaneous intracranial hypotension. Dev Med Child Neurol. 2009;51:932-5.
11. Gungor I, Gunaydin B, Tas A, Dayanir H, Altinsoy A. Post-Spinal Tinnitus Requiring Treatment: Efficacy of Epidural Blood Patch: Case Report. Turkiye Klinikleri J Med Sci 2012;32:515-9.
12. Haritanti A, Karacostas D, Drevelengas A, Kanellopoulos V, Paraskevopoulou E, Lefkopoulos A, Economou I, Dimitriadis AS. Spontaneous intracranial hypotension: clinical and neuroimaging findings in six cases with literature review. Eur J Radiol. 2009; 69:253-9.
13. Horton JC, Fishman RA. Neurovisual findings in the syndrome of spontaneous intracranial hypotension from dural cerebrospinal fluid leak. Ophthalmology 1994; 101; 244-251.
14. Karakurum-Goksel BK. Damarsal Olmayan Kafa İçi Bozukluklara Bağlanan Başağrısı. In: Inan LE eds. Nörolojide Yeni Ufuklar: Başağrıları. Ankara, Güneş Tıp Kitapevi. 2010,191-223.
15. Maher CO, Meyer FB, Mokri B. Surgical treatment of spontaneous spinal cerebrospinal fluid leaks. Neurosurg Focus. 2000; 15:9:e7.
16. Medina JH, Abrams K, Falcone S, Bhatia RG. Spinal imaging findings in spontaneous intracranial hypotension. AJR Am J Roentgenol. 2010; 195:459-64.
17. Mokri B, Parisi JE, Scheithauer BW, Piepgras DG, Miller GM. Meningeal biopsy in intracranial hypotension. Neurology 1995; 45: 1801-1807.
18. Park ES, Kim E. Spontaneous intracranial hypotension: clinical presentation, imaging features and treatment. J Korean Neurosurg Soc. 2009; 45:1
19. Rahman M, Bidari SS, Quisling RG, Friedman WA. Spontaneous intracranial hypotension: dilemmas in diagnosis. Neurosurgery. 2011; 69:4-14.
20. Russo A, Tessitore A, Cirillo M, Giordano A, De Micco R, Bussone G, Tedeschi G. A transient third cranial nerve palsy as presenting sign of spontaneous intracranial hypotension. J Headache Pain. 2011; 12:493-6.
21. Savoiardo M, Armenise S, Spagnolo P, De Simone T, Mandelli ML, Marcone A, Morciano G, Andreula C, Mea E, Leone M, Chiapparini L. Dural sinus thrombosis in spontaneous intracranial hypotension: Hypotheses on possible mechanisms. J Neurol. 2006; 253:1197-202.
22. Schievink WI, Meyer FB, Atkinson JLD, Mokri B. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg. 1996; 84: 598-60
23. Schievink WI, Schrijver I, Meyer FB, et al. A syndrome of spontaneous spinal cerebrospinal fluid leaks and skeletal features of Marfan syndrome. Ann Neurol 1998;44:458.
24. Schievink WI, Tourje J. Intracranial hypotension without meningeal enhancement on magnetic resonance imaging. J Neurosurg 2000; 92; 3:4754
25. Schievink WI, Maya MM. Cerebral venous thrombosis in spontaneous intracranial hypotension. Headache. 2008; 48:1511-9.
26. Schievink WI, Maya MM, Louy C. Cranial MRI predicts outcome of spontaneous intracranial hypotension. Neurology. 2005; 64:1282-4.
27. Schievink WI, Gordon OK, Tourje J. Connective tissue disorders with spontaneous spinal cerebrospinal fluid and intracranial hypotension. Neurosurg 2004;54:65-70.
28. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006; 17;295:2286-96.
29. Schrijver I, Schievink WI, Godfrey M, et al. Spontaneous spinal cerebrospinal fluid leaks and minor skeletal features of Marfan syndrome: a microfibrillopathy. J Neurosurg 2002; 96: 483-489.
30. Schoffer KI, Benstead TJ, Grant I. Spontaneous intracranial hypotension in the absence of magnetic resonance imaging abnormalities. Can J Neurol. Sci. 2002; 29 : 253-257.
31. Takashi K, Mima T. Cerebrospinal fluid leakage after radioisotope cisternography is not influenced by needle size at lumbar puncture in patients with intracranial hypotension. Cerebrospinal Fluid Research 2009; 6: 1-6.
32. Whitely W, Al-Shahi R, Myles L, Lueck CJ. . Spontaneous intracranial hypotension causing confusion and coma. Br J Neurosurg. 2003; 17: 4564
33. Witiw CD, Fallah A, Muller PJ, Ginsberg HJ. Surgical treatment of spontaneous intracranial hypotension secondary to degenerative cervical spine pathology: a case report and literature review. Eur Spine J. 2011; 27:422-7
34. Yoon SH, Chung YS, Yoon BW, Kim JE, Paek SH, Kim DG. Clinical experiences with spontaneous intracranial hypotension: a proposal of a diagnostic approach and treatment. Clin Neurol Neurosurg. 2011; 113:373-9.
35. Zaatreh M, Finkel A. Spontaneous intracranial hypotension. South Med J. 2002; 95: 1342-6.
36. Zada G, Solomon TC, Giannotta SL. A review of ocular manifestations in intracranial hypotension. Neurosurg 2007; 23 : 1-5.