About Bioline  All Journals  Testimonials  Membership  News

Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 59, Num. 5, 2011, pp. 761-762

Neurology India, Vol. 59, No. 5, September-October, 2011, pp. 761-762

Letter to Editor

An uncommon site of dural tear in a case of spontaneous intracranial hypotention demonstrated using contrast enhanced magnetic resonance cisternography

Maya D Bhat1, Chandrajit Prasad1, Nupur Pruthi2, MK Vasudev1, GG Sharath Kumar1

1 Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, Karnataka, India
2 Department of Neurosugery, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, Karnataka, India
Correspondence Address: Chandrajit Prasad, Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, Karnataka, India,

Date of Submission: 02-Sep-2010
Date of Decision: 02-Sep-2010
Date of Acceptance: 12-Jan-2011

Code Number: ni11226

PMID: 22019666

DOI: 10.4103/0028-3886.86556


Idiopathic or spontaneous intracranial hypotension (SIH) is a rare disorder with a prevalence of about 1 per 50,000 population [1] and presents with characteristic orthostatic headaches. [2] The diagnostic criteria also include the characteristic magnetic resonance imaging (MRI). [3] SIH almost invariably results from spontaneous cerebrospinal fluid (CSF) leak. [4] Several imaging techniques have been studied to demonstrate the site of dural leak, but none of the techniques were reliable. [5] We report an unusually high dural tear at the C2 level demonstrated on MR cisternography.

A 35-year-old lady, otherwise healthy, presented with acute-onset holocranial orthostatic headache of one and half months duration which progressed over the next 6 weeks. She also had dull interscapular pain, vomiting, and eye pain. The headache used to get relived on lying down and used to aggravate on bending forward and sitting up. There was no history of trauma. She had similar headache 10 years back just following delivery which subsided with bed rest. Neurologic examinations revealed bilateral early papilloedema and terminal neck stiffness. Computed tomography (CT) showed bilateral subdural hygromas. Initial cranial MRI revealed diffuse pachymeningeal enhancement with bilateral subdural hematomas, tonsillar descent, and decreased mamillopontine distance [Figure - 1]. Spinal MRI using high resolution T2WI and steady state imaging revealed a hyperintense collection in the epidural space from C1-C2. Intrathecal gadolinium-enhanced MR cisternography was obtained using high resolution T1W fat-saturated images of the entire spine. A distinct tear was seen at the C2 level on the left side with contrast extravasation in the epidural space [Figure - 2] and [Figure - 3]. Subsequently the patient underwent surgery with dural repair. Postoperatively, she had complete relief of orthostatic headache. Postoperative MRI of the spine did not reveal any epidural collection [Figure - 4].

SIH was first described by Schaltenbrand and is more common in females (3:1). The characteristic feature is orthostatic headache and other less common features include neck stiffness, nausea and vomiting, cranial neuropathies causing vertigo, tinnitus, photophobia, and diplopia. The characteristic MRI features include diffuse and nonnodular intense thickening and pachymeningeal enhancement with leptomeningeal sparing, subdural collections, downward displacement of brain with sagging of brain stem, engorgement of venous sinuses and enlargement of pitutiary gland. [6] SIH almost always results from a spontaneous CSF leak, often from a spinal dural defect. [4] Previously documented sites of dural tear include cervicothoracic, thoracic, and upper lumbar levels. [5] In our patient, the tear was located at the C1-C2 level, posterolaterally on the left side. Since the defect was large, epidural patch therapy was not contemplated and the patient underwent partial left C2 laminectomy. The dural rent was identified at the C2 nerve root sleeve and was closed using gel foam and muscle patch.

In our patient, the dural tear could be demonstrated by MR cisternography which was corroborated by the intraopertive findings. Contrast enhanced MR cisternography was first described by Di Chiro et al. [7] to detect intracranial CSF fistulae in Beagle dogs. Intrathecal gadopentetate dimegulmine administration in 95 people has been found to be safe with no complications. [8] Most of the studies have used 0.5 ml of intrathecal contrast diluted in 5 ml of CSF given slowly over 3-5 min. Contrast enhanced MR cisternography serves as a useful diagnostic method in cases where the site dural defect is difficult to identify.


1.Schievink WI, Meyer FB, Atkinson JL, Mokri B. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 1996;84:598-605.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Mokri B, Hunter SF, Atkinson JL, Piepgras DG. Orthostatic headaches caused by CSF leak but with normal CSF pressures. Neurology 1998;51:786-90.  Back to cited text no. 2  [PUBMED]  
3.Schievink WI, Maya MM, Louy C, Moser FG, Tourje J. Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol 2008;29:853-6.   Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Mokri B. Spontaneous intracranial hypotension. Curr Pain Headache Rep 2001;5:284-91.  Back to cited text no. 4  [PUBMED]  
5.Albayram S, Kilic F, Ozer H, Baghaki S, Kocer N, Islak C. Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. AJNR Am J Neuroradiol 2008;29:116-21.  Back to cited text no. 5    
6.Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 2006;295:2284-96.  Back to cited text no. 6    
7.Di Chiro G, Girton ME, Frank JA, Dietz MJ, Gansow OA, Wright DC, et al. Cerebrospinal fluid rhinorrhea: Depiction with MR cisternography in dogs. Radiology 1986;160:221-2.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Tali ET, Ercan N, Krumina G, Rudwan M, Mironov A, Zeng QY, et al. Intrathecal gadolinium (gadopentetate dimeglumine) enhanced magnetic resonance myelography and cisternography: Results of a multicenter study. Invest Radiol 2002;37:152-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]

Copyright 2011 - Neurology India

The following images related to this document are available:

Photo images

[ni11226f1.jpg] [ni11226f3.jpg] [ni11226f2.jpg] [ni11226f4.jpg]
Home Faq Resources Email Bioline
© Bioline International, 1989 - 2024, Site last up-dated on 01-Sep-2022.
Site created and maintained by the Reference Center on Environmental Information, CRIA, Brazil
System hosted by the Google Cloud Platform, GCP, Brazil