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Relationship of Bern Score, Spinal Elastance, and Opening Pressure in Patients With Spontaneous Intracranial
Andrew L Callen1, Jack Pattee2, Ashesh A Thaker2
1From the Neuroradiology Section (A.C., A.A.T., V.M.T., D.Z., R.T.), Department of Radiology, Headache Section (M.B., D.W., C.O.B., J.E.), Department of Neurology, and Neurosurgery (F.G.), University of Colorado Anschutz Medical Campus, Aurora; Department of Biostatistics & Informatics (J.P.), Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora and Department of Anesthesiology (I.C.), Perioperative and Pain Medicine, Stanford University, CA. andrew.callen@cuanschutz.edu.
Background And Objectives:
Existing tools to diagnose spontaneous intracranial hypotension (SIH), namely spinal opening pressure (OP) and brain MRI, have limited sensitivity. We investigated whether evaluation of brain MRI using the Bern score, combined with calculated craniospinal elastance, would aid in diagnosing SIH and provide insight into its pathophysiology.
Methods:
A retrospective chart review was performed of patients who underwent brain MRI and pressure-augmented dynamic CT myelography (dCTM) for suspicion of SIH. Two blinded neuroradiologists assigned Bern scores for each brain MRI. OP and incremental pressure changes after intrathecal saline infusion were recorded to calculate craniospinal elastance. The relationship between Bern score, OP, and elastance and whether a leak was found were analyzed.
Results:
Seventy-two consecutive dCTMs were performed in 53 patients. Twelve CSF-venous fistulae, 2 ruptured meningeal diverticula, 2 dural defects, and 1 dural bleb were found (17/53, 32%). Among patients with imaging-proven CSF leak/fistula, OP was normal in all but 1 patient and was not significantly different in those with a leak compared with those without (15.1 vs 13.6 cm H2O, p = 0.24, A = 0.40). The average Bern score in individuals with a leak was significantly higher than that in those without (5.35 vs 1.85, p < 0.001, A = 0.85), even when excluding pachymeningeal enhancement from the score (3.77 vs 1.57, p = 0.001, A = 0.78). The average elastance in those with a leak was higher than that in those without, but this difference was not statistically significant (2.05 vs 1.20 mL/cm H2O, p = 0.19, A = 0.40). Increased elastance was significantly associated with an increased Bern score (95% CI -0.55 to 0.12, p < 0.01) and was significantly associated with venous distention, pachymeningeal enhancement, prepontine narrowing, and subdural collections, but not a narrowed mamillopontine or suprasellar distance.
Discussion:
OP is not an effective predictor for diagnosing CSF leak and if used in isolation would result in misdiagnosis of 94% of patients in our cohort. The Bern score was associated with a higher diagnostic yield of dCTM. Elastance was significantly associated with certain components of the Bern score.
Insights
The Bern score on brain MRI, not spinal opening pressure, effectively aids in diagnosing spontaneous intracranial hypotension (SIH) and identifying cerebrospinal fluid (CSF) leaks. This combined approach improves diagnostic accuracy for SIH.
Area of Science:
- Neurosurgery
- Neuroradiology
- Neurology
Background:
- Spontaneous intracranial hypotension (SIH) diagnosis is challenging due to limited sensitivity of current tools like spinal opening pressure (OP) and brain MRI.
- Accurate diagnosis of SIH is crucial for timely intervention and management of associated neurological symptoms.
Purpose of the Study:
- To evaluate the diagnostic utility of the Bern score on brain MRI, combined with craniospinal elastance calculation, for diagnosing SIH.
- To investigate the pathophysiology of SIH by analyzing the relationship between imaging findings, OP, and elastance.
Main Methods:
- Retrospective chart review of 53 patients with suspected SIH undergoing brain MRI and pressure-augmented dynamic CT myelography (dCTM).
- Two blinded neuroradiologists assigned Bern scores to brain MRIs.
- Spinal OP and pressure changes after intrathecal saline infusion were measured to calculate craniospinal elastance.
Main Results:
- Cerebrospinal fluid (CSF) leaks/fistulae were identified in 32% of patients.
- Spinal OP did not significantly differ between patients with and without CSF leaks.
- The Bern score was significantly higher in patients with CSF leaks (p < 0.001), demonstrating higher diagnostic yield.
- Craniospinal elastance showed a trend towards being higher in patients with leaks but was not statistically significant (p = 0.19).
- Increased elastance correlated with higher Bern scores and specific MRI findings like venous distention and pachymeningeal enhancement.
Conclusions:
- Spinal opening pressure is an unreliable diagnostic marker for CSF leaks in SIH, potentially leading to misdiagnosis.
- The Bern score on brain MRI significantly enhances the diagnostic yield of dCTM for SIH.
- Craniospinal elastance is associated with specific SIH imaging features and Bern score components, offering insights into pathophysiology.
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