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A few cases have presented with stupor as a result of downward transtentorial displacement of the diencephalic region (Pleasure et al) or an upper cervical myelopathy caused by downward deformation and displacement of the spinal cord (Miyazaki et al) In many such patients, there has been a tear in the delicate arachnoid surrounding a nerve root, with continuous leakage of CSF The site of the leak is dif cult to ascertain except when it occurs into the paranasal sinuses (CSF rhinorrhea) In a series of 11 patients with spontaneous intracranial hypotension, a putative leak was found by radionuclide cisternography or CT myelography (the preferred procedure) in the cervical region or at the cervicothoracic junction in 5 patients, in the thoracic region in 5, and the lumbar region in 1 (Schievink et al).

In the patients who underwent surgical repair, a leaking meningeal diverticulum (a so-called Tarlov cyst) was found and could be ligated This seems to be the most common cause A blood patch, as described above, may also be useful and should be attempted before resorting to surgery Recumbency for a few days thereafter permits the pressure to build up, and there has been no recurrence in the cases that we have encountered Others, however, have reported repeated episodes of orthostatic headache As noted above, a helpful diagnostic sign is prominent dural enhancement with gadolinium on the MRI (Fig 30-4), a phenomenon attributed by Fishman and Dillon to dural venous dilatation; this nding may extend to the pachymeninges of the posterior fossa and the cervical spine According to Mokri and colleagues, biopsy of the dura and underlying meninges in these cases shows broblastic proliferation and neovascularity with an amorphous subdural uid.

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There may be subdural effusions and mass effect, either on the cerebral convexities, temporal lobes, optic chiasm, or cerebellar tonsils Using ultrasound, Chen and colleagues have also described an enlarged superior ophthalmic vein and increased blood ow velocity in this vessel, both of which normalize after successful treatment Rarely, a case of intracranial hypotension becomes chronic; the headache is then no longer responsive to recumbency Mokri and colleagues have also made the point that orthostatic headache and diffuse pachymeningeal enhancement on MRI may occur in the presence of normal CSF pressures; observation of these characteristic features should prompt a search for the site of CSF leakage despite the normal pressure The use in hydrocephalus of a one-way shunt valve may be complicated by a syndrome of low CSF pressure Reference has already been made to this syndrome and to the slit ventricles in children who have been treated for hydrocephalus.

You can also invoke CellCLI with the e option and supply the CellCLI command directly at the OS command line as shown next. This command will display the same result as the previous example.

Usually the valve setting is too low, and readjustment to maintain a higher pressure is corrective Also appropriate to mention here are CSF leaks that occur.

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