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Letter to the Editor
Locating the site of cerebrospinal fluid leak in a patient with low cerebrospinal fluid pressure
Localización del punto de fuga de líquido cefalorraquídeo en un caso de hipotensión de líquido cefalorraquídeo
G. García Martína,
Corresponding author
guillerminagmartin@gmail.com

Corresponding author.
, A.O. Rodríguez Bellia, F. Padilla Parradoa, R. Aguilar Cuevasb
a Servicio de Neurología, Hospital Virgen de la Victoria, Málaga, Spain
b Servicio de Radiodiagnóstico, Hospital Virgen de la Victoria, Málaga, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Low cerebrospinal fluid &#40;CSF&#41; pressure due to meningeal tear is an infrequent but widely reported condition&#44; often associated with typical neuroimaging findings that are helpful for diagnosis&#46; However&#44; it is relatively infrequent for the site of the CSF leak to be located&#44; especially in cases secondary to mild trauma&#59; the upper thoracic spine and cervico-thoracic junction are the most frequent locations&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Locating the site of the CSF leak is relevant due to the possible prognostic implications&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case with striking neuroimaging findings&#44; which enabled us to clearly locate the site of the CSF leak at the lumbar level &#40;a rare location&#41;&#59; this was essential to establish a definitive treatment&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient was a 30-year old woman with no relevant personal history&#44; who visited our department due to progressive headache of 48<span class="elsevierStyleHsp" style=""></span>hours&#8217; duration&#46; Headache started 2<span class="elsevierStyleHsp" style=""></span>hours after the patient lifted a 47-inch television set&#46; The headache was frontal and drug-resistant&#44; and was accompanied by nausea and vomiting&#46; It improved only with bed rest and intensified when the patient stood&#46; Physical examination revealed nuchal rigidity with positive Kernig and Brudzinski signs&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We suspected post-traumatic low CSF pressure headache&#44; and the patient was admitted to the neurology department&#46; A contrast-enhanced brain magnetic resonance imaging &#40;MRI&#41; scan only revealed generalised smooth dural enhancement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#59; a cervical&#44; dorsal&#44; and lumbar MRI with and without contrast showed no significant alterations&#59; an MR myelography revealed an opening pressure of 1<span class="elsevierStyleHsp" style=""></span>cm of water and bilateral extravasation of the contrast agent and CSF through the L1&#47;L2&#44; L2&#47;L3&#44; L3&#47;L4&#44; L4&#47;L5 roots&#59; this was compatible with CSF leak&#44; possibly associated with rupture of the meningeal diverticula &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">These findings confirmed the diagnosis of low CSF pressure secondary to meningeal tear of the L1&#47;L2&#44; L2&#47;L3&#44; L3&#47;L4&#44; and L4&#47;L5 roots of post-traumatic aetiology&#44; associated with rupture of the meningeal diverticula&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As the site of CSF leak was located by MRI&#44; symptoms could be controlled by placing an autologous blood patch at the site of the fistula&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Minor trauma has been described as a cause of CSF leaks&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> although the site is not always located&#46; If this entity is not previously suspected&#44; the diagnosis may be overlooked in these cases&#44; given the apparent unimportance of the trauma&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The most frequent findings in contrast MRI<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> are&#58; &#40;a&#41; diffuse dural enhancement &#40;the most frequent and characteristic&#41; and pituitary enlargement caused by venous vasodilation compensating for the decreased CSF volume&#44; leading to meningeal and pituitary gland congestion&#44; and in turn&#44; to increased contrast uptake<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a>&#59; and &#40;b&#41; presence of subdural fluid collections &#40;intracranial and spinal&#41;&#46; Intracranial collections are secondary to venous rupture after a decrease in CSF volume and downward displacement of the brain&#59; spinal collections are mainly caused by the leakage and physical accumulation of CSF due to the effect of gravity&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> as in the case of our patient&#46; In any case&#44; rostrocaudal gradient and the presence of subdural collections are relatively infrequent&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Locating the site of CSF leak is important because it may facilitate treatment with autologous blood patches at the site of the fistula&#44; with the upper thoracic spine or cervico-thoracic junction being the most frequent locations&#44; as mentioned previously&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The interest of this case is the unusual location of the site of the CSF leak&#44; and the neuroimaging findings&#44; which clearly located the site of the CSF leak by showing the presence of a spinal subdural fluid collection and the extravasation of contrast agent at the level of the lumbar roots&#44; which is a relatively infrequent occurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p></span>"
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ISSN: 21735808
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos