Abstract Details

Title Severe Intracranial Hypotension Secondary to Cerebrospinal-Venous Fistula in a Patient with History of Spinal Decompression and Fusion

Topic Neuro Trauma and Critical Care

Presentation(s) P6 - Poster Session 6 (11:45 AM-12:45 PM)

Poster/Presentation
Number 7-002

Objective To discuss a case of severe intracranial hypotension secondary to CSF-venous fistula, with an emphasis on clinical and radiographic features, pathophysiology, and treatment.

Background Case: A 58-year-old woman with remote history of Chiari 1 malformation status post C3-T1 decompression and fusion presented with three weeks of positional headaches followed by acute onset lethargy and encephalopathy. Brain MRI showed crowding of the cerebellar tonsils which can be seen in Chiari 1 malformation, but the presence of acute subdural hematomas, diffuse pachymeningeal enhancement, and effacement of the suprasellar cistern with pituitary enlargement were together highly suggestive of intracranial hypotension from a cerebrospinal fluid (CSF) leak. Spinal MRI showed subdural hematomas at the T5-T9 levels without longitudinal extradural collections, concerning for CSF-venous fistula (CVF). CT myelogram confirmed right-sided CVF at the T1 level. She underwent transvenous embolization of the fistula with resolution of symptoms.

Design/Methods NA

Results NA

Conclusions Spinal CVFs, which are responsible for up to 20% of spinal CSF leaks, are aberrant connections between the spinal subarachnoid space and epidural venous plexus that cause loss of CSF into the venous system. Rarely, resultant intracranial hypotension leads to altered level of consciousness and impending tonsillar herniation, a neurologic emergency. Definitive treatment is endovascular or open repair, but Trendelenburg positioning and intrathecal saline injection via a lumbar drain may serve as temporizing measures. Literature on risk factors for CVFs remains sparse, and it is unclear if our patient’s history of spinal decompression and fusion were related to development of CVF, or whether occult CVF was previously misdiagnosed.

Authors/Disclosures
Julia Greenberg, MD PRESENTER	Dr. Greenberg has a non-compensated relationship as a Editorial Board Member with Neurology Resident and Fellow Section that is relevant to AAN interests or activities.
Benjamin M. Jadow, MD	Mr. Jadow has nothing to disclose.
Christina Kallik, MD	Dr. Kallik has nothing to disclose.
Joseph Boonsiri, MD	Dr. Boonsiri has nothing to disclose.
Svetlana Kvint, MD	Dr. Kvint has nothing to disclose.
Eytan Raz (NYU Langone Health)	Eytan Raz has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Balt, Cerenovus, Imperative Care, Medtronic, Microvention, Phenox, QApel, Route92, Siemens, Vasorum. Eytan Raz has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for AHA. Eytan Raz has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for various law firms.
Ariane Lewis, MD, FAAN (NYU Langone Medical Center)	Dr. Lewis has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Seminars in Neurology. Dr. Lewis has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Clinical Neuroscience.

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