Article Figures & Data
Figures
- Fig 1.
Measurement of the ONS. A, Coronal STIR sequence of the orbital contents shows the normal appearance of the optic nerve surrounded by a high-signal-intensity rim representing CSF in the ISSON (arrow). B, Schematic drawing of the ONS including the optic nerve and surrounding CSF rim.
- Fig 2.
Patient sample 1. Cranial MR imaging (coronal STIR sequence) of a 49-year-old woman (patient 6) with CSH due to spontaneous CSF leak in the spinal dura before (A and C) and on follow-up imaging after (B and D) successful therapy with an epidural blood patch. Imaging of the orbital contents reveals a lack of the normal peri-optical CSF rim in the ISSON (arrows in A, collapsed ONS), which normalized with therapy (arrows in B). Width of the ISSON is 1.3 mm (position 1), 1.3 mm (position 2), 1.0 mm (position 3), and 0.9 mm (position 4) on follow-up. Lower normal width of the ISSON is 1 mm (position 1) and 0.9 mm (positions 2–4). C, Subdural effusion (asterisks), narrow ventricles (white arrows), and an enlarged pituitary gland (curved arrow) are in agreement with CSH. Following therapy, the subdural effusion and the pituitary gland appear smaller and the ventricles regain normal size (D).
- Fig 3.
Patient sample 2. MR imaging of a 33-year-old woman (patient 9) with post-LP syndrome before (A and C) and on follow-up after successful conservative treatment (B and D). CSF in the ONSs is reduced to a minimum amount, normalizing after treatment (arrows in A and B). The pituitary gland is enlarged (8.3 mm in height), regaining normal size on follow-up (curved arrows in C and D). Very thin subdural hygromas could only be detected by FLAIR imaging (not shown). There is a minimal increase in ventricle size (D) after treatment.
Tables
Patient No. Sex Age (yr) Etiology of CSH Opening Pressure on LP 1 M 72 Idiopathic Dry tap 2 M 23 Idiopathic 11 cm H2O 3 M 63 Idiopathic Dry tap 4 F 40 Idiopathic Dry tap 5 F 23 Idiopathic N.M. 6 F 49 Idiopathic Dry tap 7 F 59 Idiopathic Dry tap 8 M 39 Post-LP N.M. 9 F 33 Post-LP N.M.. 10 F 24 Post-LP N.M. 11 M 70 Post-LP N.M. 12 M 29 Post-LP N.M. 13 M 18 VP shunt N.M. 14 F 20 VP shunt N.M. 15 F 18 VP shunt N.M. 16 F 67 VP shunt N.M. 17 F 44 VP shunt N.M. 18 F 43 VP shunt N.M. 19 F 35 VP shunt N.M. -
a Patients were sorted according to the etiology of CSH.
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All Patients A) Headache that worsens within 15 minutes after sitting or standing and improves after lying, with at least 1 of the following criteria: 1) Neck stiffness, 2) tinnitus, 3) hypacusis, 4) photophobia, 5) nausea Subgroup of patients with post-LP syndrome B) Headache develops within 5 days after dural puncture C) Headache resolves either 1) Spontaneously within 1 week 2) Within 48 hours after effective treatment of the spinal fluid leak Subgroup of patients with idiopathic low CSF pressure syndrome B) At least 1 of the following: 1) CSF opening pressure <60 mm H2O in sitting position 2) Evidence of CSF leakage on conventional myelography, CT myelography, or cisternography 3) Evidence of low CSF pressure on MRI (eg, pachymeningeal enhancement) C) No history of dural puncture or other cause of CSF fistula D) Headache resolves after epidural blood patching Subgroup of patients with shunt overdrainage B) Previous shunt operation C) Evidence of low CSF pressure on MRI (eg, pachymeningeal enhancement) -
a Adapted with permission from the Headache Classification Subcommittee of the International Headache Society.6
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Patient No. ISSON Width ISSON Width (Gross Visual Inspection) Position 1 Position 2 Position 3 Position 4 –/N MM –/N MM –/N MM –/N MM –/N 1 N 1.1 – 0 – 0 – 0 – 2 – N.A. – 0.6 – 0.6 – 0.7 – 3 N 1.2 N 1.1 – 0.7 – 0.8 – 4 – 0 – 0 – 0 – 0 – 5 – 0 – 0 – 0 – 0 – 6 – 0 – 0 – 0 – 0 – 7 – 0 – 0 – 0 – 0 – 8 – 0 – 0 – 0 – 0 – 9 N 1.6 N 0.9 – 0.7 – 0 – 10 N 1.2 – 0.6 – 0.7 – 0 – 11 – 0.8 – 0 – 0 – 0.8 – 12 N 1.1 – 0 – 0 – 0 – 13 – 0 – 0 – 0 – 0 – 14 N 1.2 – 0 – 0 – 0 – 15 – 0.8 – 0 – 0 – 0 – 16 – 0.7 – 0 – 0 – 0 – 17 – 0 – 0 – 0 – 0 – 18 N 1.4 N 1.2 – 0.7 – 0 – 19 – 0 – 0 – 0 – 0 – Mean 0.6 0.2 0.2 0.1 SD 0.6 0.4 0.3 0.3 Sensitivity 61% 84% 100% 100% 100% CI (95%) 36%–83% 60%–97% 85%–100% 85%–100% 85%–100% ICCc 0.908 0.859 0.862 0.824 κc 1 -
a Measurements were obtained in 4 intraorbital positions approximately 3, 6, 10, and 20 mm behind the eyeball. Specificity was 97% each.
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b –indicates decreased (<1.0 mm, [position 1]; <0.9 mm, [positions 2–4]). Regarding gross visual inspection,–corresponds to a reduction or absence of CSF in the ISSON.
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c ICC and κ values were computed for results of 3 readers.
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Patient No. Increased Pituitary Heightb Engorged Venous Sinuses Narrow Ventricles Dural Enhancement Subdural Effusion Brain Sagging +/N MM +/N +/N +/N +/N + 1 N 5.2 N + + + N 2 N 3.8 N N N N N 3 N 3.8 + N + + + 4 N 6.3 + + + + + 5 + 11.7 + N + + + 6 + 8.0 + + N.P. + + 7 + 6.7 + + N.P. + N 8 + 6.0 + N N.P. N N 9 + 8.3 + + + + N 10 + 8.1 + N N N N 11 N 3.9 N N N N N 12 + 7.7 + N + + N 13 N 3.0 + N + + N 14 N 6.4 + + N.P. + N 15 + 7.1 + + N.P. N N 16 + 9.6 + N + N + 17 + 7.6 + + + + N 18 + 9.6 + + + + N 19 + 7.8 + N + + + Frequency 63% 84% 47% 79% 68% 32% 95% CI 38%–84% 60%–97% 24%–71% 49%–95% 43%–87% 13%–57% κc 0.775 0.579 0.869 1 0.652 ICCc 0.974 -
a + indicates increased value (for quantitative measurement of the pituitary height); +, positive (for qualitative signs).
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b Maximum normal pituitary height is 5.6 mm (men), 6.9 mm (women, 16–40 years of age), 5.8 mm (women, 41–62 years of age), and 6.0 mm (women, >62 years of age).10
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c ICC and κ values were computed for the results of 3 readers.
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