Intracranial hypotension following traumatic brain injury: a diagnostic and therapeutic challenge.

BACKGROUND: Intracranial hypotension (IH) is a recognised cause of coma, however, the diagnosis is often challenging, especially in patients with superimposed traumatic brain injury (TBI). CASE REPORT: We report a case of a 67-year-old patient who became comatose following evacuation of bilateral acute subdural haematomas with concurrent respiratory failure. Imaging and intraparenchymal intracranial pressure (ICP) monitoring confirmed secondary IH. She was managed with an epidural blood patch, and a 72 hours period in the trendelenberg position guided by ICP monitoring and clinical assessment. She subsequently made an excellent neurological recovery from an initial Glasgow coma scale (GCS) of 3 to a GCS of 15. CONCLUSION: A diagnosis of secondary IH can easily be missed in patients who have suffered a primary brain injury. In patients with a poor neurological recovery, clinicians should rule out secondary IH as a potential cause as immediate treatment can lead to a profound clinical improvement

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There is discussion whether medicines can be authorized on the market based on evidence from surrogate endpoints. We assessed opinions of different stakeholders on this topic.We conducted an online questionnaire that targeted various stakeholder groups (regulatory agencies, pharmaceutical industry, academia, relevant public sector organisations) and medical specialties (cardiology or nephrology vs. other). Participants were enrolled through purposeful sampling. We inquired for conditions under which surrogate endpoints can be used, the validity of various cardio-renal biomarkers and new approaches for biomarker use.Participants agreed that surrogate endpoints can be used when the surrogate is scientifically valid (5-point Likert response format, mean score: 4.3, SD: 0.9) or when there is an unmet clinical need (mean score: 3.8, SD: 1.2). Industry participants agreed to a greater extent than regulators and academics. However, out of four proposed surrogates (blood pressure (BP), HbA1c, albuminuria, CRP) for cardiovascular outcomes or end-stage renal disease, only use of BP for cardiovascular outcomes was deemed moderately accurate (mean: 3.6, SD: 1.1). Specialists in cardiology or nephrology tended to be more positive about the use of surrogate endpoints.Stakeholders in drug development do not oppose to the use of surrogate endpoints in drug marketing authorization, but most surrogates are not considered valid. To solve this impasse, increased efforts are required to validate surrogate endpoints and to explore alternative ways to use them

Infectious endocarditis complicated by an ischemic stroke and revealing Marfan syndrome

Marfan syndrome is a systematic genetic disease of the connective tissue. The cardiac affection would predict the prognosis and ischemic stroke might complicate it. The purpose of this work is to discuss the mechanisms of the ischemic stroke in Marfan syndrome which have to be considered in all young patients of ischemic strokes. We report the case of a 17-year-old male patient who presented with right hemiparesis with brachio-facial dominance, hemihypoesthesia and Broca's aphasia; these symptoms were followed by partial right somato-motor epileptic seizure. The cerebral computed tomographic (CT) scan demonstrated early signs of ischemic stroke in the left Sylvian artery. Cardiovascular examination revealed a systolic murmur in the mitral site. Marfan syndrome with infectious endocarditis complicated by ischemic stroke was diagnosed. However, the family pathological history was negative. The Marfan syndrome diagnosis was approved considering the following criteria: Ligamentous hyperlaxity, crystalline ectopia and mitral valve prolapsus with mitral insufficiency. The patient benefited of antibiotherapy for 4 weeks. The patient underwent sessions of motor physical therapy and orthophonic rehabilitation. Then, cardiac surgery was carried out and valvuloplasty was performed. The surgical treatment confirmed the presence of mitral insufficiency and prolapsus of the big mitral valve and multiple friable anterior-posterior vegetations with broken cordage of the small mitral valve. Replacement of the mitral valve was achieved, and the post-surgery follow-ups were simple. The diagnosis of Marfan syndrome was based on well-defined criteria. The evolution of the patient was marked by a complete improvement of the cardiac and motor deficits, and disappearance of the Broca's aphasia. A fibroelastic disease such Marfan syndrome has to be considered in unexplained ischemic stroke in all young patients. Hence, the diagnosis of Marfan syndrome involves an anticipation of the neurovascular complications by early cardiovascular care

Neurovisceral phenotypes in the expression of psychiatric symptoms

This review explores the proposal that vulnerability to psychological symptoms, particularly anxiety, originates in constitutional differences in the control of bodily state, exemplified by a set of conditions that include Joint Hypermobility, Postural Tachycardia Syndrome and Vasovagal Syncope. Research is revealing how brainbody mechanisms underlie individual differences in psychophysiological reactivity that can be important for predicting, stratifying and treating individuals with anxiety disorders and related conditions. One common constitutional difference is Joint Hypermobility, in which there is an increased range of joint movement as a result of a variant of collagen. Joint hypermobility is over-represented in people with anxiety, mood and neurodevelopmental disorders. It is also linked to stress-sensitive medical conditions such as irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia. Structural differences in 'emotional' brain regions are reported in hypermobile individuals, and many people with joint hypermobility manifest autonomic abnormalities, typically Postural Tachycardia Syndrome. Enhanced heart rate reactivity during postural change and as recently recognised factors causing vasodilatation (as noted post prandially, post exertion and with heat) is characteristic of Postural Tachycardia Syndrome, and there is a phenomenological overlap with anxiety disorders, which may be partially accounted for by exaggerated neural reactivity within ventromedial prefrontal cortex. People who experience Vasovagal Syncope, a heritable tendency to fainting induced by emotional challenges (and needle/blood phobia), are also more vulnerable to anxiety disorders. Neuroimaging implicates brainstem differences in vulnerability to faints, yet the structural integrity of the caudate nucleus appears important for the control of fainting frequency in relation to parasympathetic tone and anxiety. Together there is clinical and neuroanatomical evidence to show that common constitutional differences affecting autonomic responsivity are linked to psychiatric symptoms, notably anxiety

Epidural Blood Patches in a Patient With Multi-level Cerebrospinal Fluid Leakage That Was Induced by Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is considered to be a very rare disorder. It is characterized by an orthostatic headache that is aggravated with the patient in the upright position and it is relieved by the patient assuming the supine position. SIH is caused by a spontaneous spinal cerebrospinal fluid leakage without the patient having undergone trauma, surgery or dural puncture or having any other significant medical history. An autologous epidural blood patch (EBP) is effective in relieving SIH. We report here on a case of SIH with cerebrospinal fluid leakage at the upper cervical vertebral level and the middle thoracic vertebral level. The points of leakage were identified by radionuclide cisternography, and this patient was successfully managed by injecting an EBP at each level of leakage

Intracranial hypotension secondary to spinal arachnoid cyst rupture presenting with acute severe headache: a case report

<p>Abstract</p> <p>Introduction</p> <p>Headache is a common presenting complaint and has a wide differential diagnosis. Clinicians need to be alert to clues that may suggest an underlying secondary aetiology. We describe a novel case of headache secondary to intracranial hypotension which was precipitated by the rupture of a spinal arachnoid cyst.</p> <p>Case report</p> <p>A 51-year-old Indian female presented with sudden onset severe headache suggestive of a subarachnoid haemorrage. Investigations including a computed tomography brain scan, cerebrospinal fluid examination and a magnetic resonance angiogram were normal. The headache persisted and magnetic resonance imaging revealed bilateral thin subdural collections, a spinal subarachnoid cyst and a right-sided pleural effusion. This was consistent with a diagnosis of headache secondary to intracranial hypotension resulting from spinal arachnoid cyst rupture.</p> <p>Conclusions</p> <p>Spinal arachnoid cyst rupture is a rare cause of spontaneous intracranial hypotension. Spontaneous intracranial hypotension is a common yet under-diagnosed heterogeneous condition. It should feature significantly in the differential diagnosis of patients with new-onset daily persistent headache.</p

Reversal in the Diameter of the Superior Ophthalmic Vein after an Epidural Blood Patch in a Case of Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is caused by single or multiple cerebrospinal fluid (CSF) leaks in the spine with the prototypical symptom of postural headache. One of the characteristic MRI features in SIH is intracranial venous engorgement. This report presents a case of SIH with engorgement of the bilateral superior ophthalmic veins (SOVs) which resume their normal diameters by the third day of successful epidural blood patches (EBPs). We define this phenomenon as the "reversal of the SOV" sign