arterial spin labeled brain perfusion in patients with disorders of intracranial pressure: a...

Arterial Spin Labeled Brain Perfusion in Patients with Disorders of Intracranial Pressure:

A Prospective Study of Changes Related to Measured Cerebrospinal Fluid PressureASNR 53rd Annual Meeting – Poster EP-39, Control # 1239

Amit M. Saindane, M.D.

Deqiang Qiu, Ph.D.

John F. Holbrook, M.D.

John Oshinski, Ph.D.

Department of Radiology and Imaging Sciences

Emory University School of Medicine

Disclosures

The authors have no relevant disclosures.

Background: Idiopathic Intracranial Hypertension (IIH)

Friedman DI et al. Neurology. 2002;59:1492-1495

Syndrome with elevated intracranial pressure (ICP) without

identifiable cause

Associated orbital and skull base MRI findings

Background: Spontaneous Intracranial Hypotension (SIH)

Orthostatic headaches with low ICP due to CSF leak

Associated imaging signs of “brain sag”

Background:

ICP estimated through lumbar puncture

(LP) and CSF manometry to measure an

opening pressure (OP).

If OP elevated, therapeutic CSF removal

performed to decrease ICP, with a closing

pressure (CP) checked.

If clinical diagnosis of SIH (generally will

have low OP), therapeutic epidural blood

patch may be performed to increase ICP.

Purpose:

To assess changes in arterial spin labeled (ASL) brain

perfusion following lumbar puncture with CSF removal in

patients with know or suspected disorders of ICP (IIH and

SIH).

Methods: Patients

IRB Approved prospective study

5 women with known/suspected ICP disorders

2 with known diagnosis of IIH under treatment

2 with suspected IIH

1 with suspected SIH

Methods: Patient Protocol

MRI Part 1(with ASL Perfusion)

<15 min

LP with OP Measurement

<15 min

n=4 TherapeuticCSF Removal

and CP Measurement

MRI Part 2(with ASL Perfusion)

n=1 2 hours

TherapeuticEpidural

Blood Patch

MRI Part 2(with ASL Perfusion)

Methods: MR Imaging

3.0-T Siemens Trio MRI Unit

3D GRASE ASL sequence

Whole brain mean cerebral blood flow (CBF) calculated

Results: Known/Suspected IIH

Patients 1 and 2 with known medically treated IIH had normal OP

Patients 3 and 4 with suspected IIH had elevated OP

OP (cm water)

CSF Removed (ml)

CP (cm water)

Pre-LP CBF (ml/100g/min)

Post-LP CBF (ml/100g/min)

% Change from Baseline

Patient 1 13 11 12 35.6 33.6 -5.6%

Patient 2 16 7 11 46.3 43.6 -5.8%

Patient 3 35 14 20 29.1 31.1 +6.9%

Patient 4 26 11 12 47.4 47.7 +0.6%

Results: SIH Patient

Patient 5 met diagnostic criteria for SIH

OP=14.5 cm water. No CSF withdrawn. CP not measured.

CBF increased from 34.2 ml/100g/min to 43.9 ml/100g/min (28%)

following blood patch with resolution of positional headaches.

Limitations

Small number of patients.

Closing pressure not available for SIH patient.

Medical treatment of IIH patients may impact effect of CSF

removal on CBF.

Optimal timing for post-LP MRI is unknown. It may take greater

time for brain CBF to adapt to removal of CSF.

Conclusions

In IIH patients immediately following LP and CSF removal, there

is not a substantial change in brain CBF. This may reflect chronic

adaptation to high ICP or insufficient time for the CBF to re-

equilibrate after LP and CSF removal

In one SIH patient 2 hours following therapeutic epidural blood

patching, we observed an large (28%) increase in CBF.