September 15, 2019
Cerebral Spinal Fluid Disorders: Frequently Asked Questions

Cerebral Spinal Fluid Disorders: Frequently Asked Questions

[MUSIC] Well, normal pressure
hydrocephalus is a type of hydrocephalus which occurs
in the elderly patient. Normal refers to
the amount of pressure and it’s not high in these patients. Hydrocephalus means
basically water in the head. Many times when water builds up
in the head, pressure builds up. But in these elderly patients it
stays in the normal range, and the symptoms are imbalance,
problems with memory, and sometimes problems
with bladder control. [MUSIC] Normal pressure hydrocephalus is
diagnosed really in three steps. First, you have to be suspicious
of it based on the symptoms. The triad of
symptoms in gate and in cognition, in memory,
and in bladder control. Once you’re suspicious,
you have to ask the question, is fluid building up? Because that’s what
hydrocephalus is, and for that you need an image. The image can be a CT or an MRI,
but we have to see that fluid is building up to call
it a hydrocephalus. Finally, in the third
step we have to found out if it can be treated by a shunt,
if it’s normal pressure hydrocephalus that’s
treatable by removing fluid. And we do a trial removal at
that stage to make sure you have NPH that can be treated. [MUSIC] Normal pressure
hydrocephalus does not have a medical treatment. There’s no medicines for it. Basically, we try and drain extra fluid off
in a controlled way. To do that we have
to put a shunt in. And a shunt is basically a tube
that runs from the fluid in the brain, from the ventricle
is the fluid space, down under the skin, and
then most often we have it dripping into the area
in the abdominal cavity. Everything’s underneath
the skin and it can’t be seen. [MUSIC] Pseudotumor cerebri is
a disorder where there’s a high pressure in the head. And the high pressure is due
to veins in the head that are dilated, and the extra
amount of blood in there, which increases
the pressure generally. This is different from other
situations where the pressure may be normal, as in normal
pressure hydrocephalus, or other situations where
the pressure may even be low. In pseudotumor cerebri, we have people present really
often in young adulthood. And although males and females
can present, often it is in females and very often it is in
people with some extra weight. Pseudotumor cerebri’s
a bit of a misnomer. It was originally
described as pseudotumor because people thought
it was tumor, and that’s why the person
had the high pressure. But there’s no tumor
involved at all. So we have to remember
the word pseudo. Another perhaps better name for
it is intracranial hypertension, and that means high
pressure in the head. [MUSIC] The diagnosis of pseudotumor
cerebri really involves two elements. One, we look in the eyes. With the eye exam we can see if
there’s any pressure that’s in the head because the eyes often
do reflect in something called papilledema, swelling of
the back of the eyes. We could see that there’s
pressure in the head. The second thing is
to actually measure the pressure in the head. That could be done
through a spinal tap or it’s called a lumbar puncture. Or sometimes we do it
through intracranial pressure monitoring, which is actually
a pressure monitor which senses the pressure right in the head. If we know there’s
high pressure and especially if we
see it in the eyes, then we know the person
has pseudotumor cerebri. [MUSIC] The treatment options for pseudotumor cerebri run from
the medical to the surgical. First, increased weight
can contribute to the high pressure in your head. So we ask all patients as
possible, and sometimes that even means surgical
procedures to reduce weight. Another treatment
can be medical, and this a treatment called Diamox. It’s a medicine that reduces
the amount of fluid that’s made in the head and
reduce the pressure. Between those two options,
pseudotumor can be treated probably more than
half the time. However, when pressure
remains high, when vision is still endangered,
and vision can actually get severely diminished, or
there can even be blindness, then surgery is
needed as an option. The surgical options
are shunting, which is a tube that runs from
the ventricles, again, usually the peritoneal cavity, usually
it’s the abdominal cavity, but it can run other places as well. But there are other
options as well. Because the pressure
can cause blindness, the pressure actually compresses
the nerve going out to the eye. And the ophthalmologist can
do what’s called an optic sheath fenestration. So they specifically open up
the fluid area around the optic nerve to decompress it. So that’s another additional
option, especially if vision is threatened specifically,
which it can be. The other one is shutting,
as I mentioned. And a third option involves
what we call venous stenting, and this gets back to what
pseudotumor cerebri really is. I mentioned that it’s
a dilation of the veins, an increased pressure
in the veins. That is often because there’s a
blockage somewhere in the veins, which causes the blood
to back up behind it. We can sometimes see that
blockage in the veins in the back of the head, and this is a not infrequent
cause of pseudotumor cerebri. In this case, very much like
the cardiologist can go up the vascular tree and
use a stent to open up a vessel. The invasive radiologist can go
also up the veins of the body to the veins back here and stent them open, and therefore
relieve that obstruction and let the blood flow, the venous blood
flow come out more regularly. So the options are venous
stenting, shunting, and the medical treatments. [MUSIC] Cerebral spinal fluid leaks have
been known for years because the brain is surrounded by
fluid, as is the spinal cord. And when you get
a lumbar puncture, sometimes the hole
back there can leak. We used to call them
lumbar puncture headaches, LP headaches. Whenever you stand up,
you get very bad headaches. However, what we also know is
these CSF leaks can occur for many other reasons. They can present in adults of
any age, men and women, and sometimes it’s because
of a known trauma, a trauma to the head, where
there may be fluid leaking, or trauma to the spinal cord. The trauma could be an accident
or it could be surgical trauma. But also is very interesting
is that unfortunately this can happen without any known trauma,
what we consider spontaneously, and can be very unknown as
to where the exact leak is. So these CSF leaks occur and
lower the pressure in the head, and this is a situation where
the CSF pressure is low. And we call it
intracranial hypotension. [MUSIC] When we have CSF leaks, sometimes they’re
quite apparent. Sometimes fluid is
dripping from the nose or there’s a swelling in the back,
but that’s not often the case. Sometimes we know by the history
that there’s a break in the skull or
we can see it on an image. What we look at in
an image is not only for breaks in the skull, but sometimes we can see that the
brain is actually sagging down and pulling downward. And that can cause severe
headaches whenever a person stands up. It can also cause problems with
your nerve control of your face, your cranial nerves. It can even make you lethargic
and it could be very dangerous. So the whole brain can sag and
we can see that in the MRI. With an MRI of the spinal cord, sometimes, unfortunately not
frequently enough, we can see where the leak is coming from
on a standard MRI image. More often, we have to find
out if the pressure’s low by measuring the pressure
in the head and determining it’s low directly. And by doing special studies, and some of them require a tube
or catheter going into the spine to look for
where these leaks might be. We inject dyes or
tracers and see how it might come out of the spinal canal and
where the leak might be. We have to find specifically
where the leak is in order to treat it. [MUSIC] When a person has a CSF leak, sometimes we just
hope it goes away. We tell people to lay down for a
while, drink some fluids, drink some caffeine, and sometimes
it does go away in a few days. Obviously, the problems that are
more difficult to face is when they continue, when there’s a leak that
does not stop on its own. In this case, one of the first
things that’s often tried is what we call a blood patch. And it’s an empirical
blood patch. It’s putting a wad of
a person’s own blood clot over the spinal canal to try and
close up a leak. Of course, that only works with
leaks that it can find down low in the bottom of the spinal
cord and close up. Many times these leaks can be
up and down the spinal cord, and we have to go and find them. So we use what’s called
a targeted blood patch. And in this case our invasive
radiologist can go up and look for where the leak is along
the spinal canal, find out the level, and then right
through the skin with a needle. The patient’s kept
very comfortable, the patch is made
right over the leak. Those are the main ways
that we treat them, with the addition of actual
surgical operation which we sometimes have to do an open
operation to go in and close it. We hope that we can usually
close these up through these patching techniques. [MUSIC]

22 thoughts on “Cerebral Spinal Fluid Disorders: Frequently Asked Questions

  1. I have NPH and Epilepsy for 15 yrs now it drives me nuts not being able to do much ( like going to pick up groceries , etc its effecting my walking , talking can't even think straight sometimes am 58 now and going downhill

  2. My daughter is 10 and underweight she is very active. She was just diagnosed last month her pressure was 29. It has already effected her eyesight

  3. My husband underwent endoscopic CSF leak repair along with Septoplasty on July 19, 2017 through his right nostril. As the exact location of the leak was not found, based on the presumptions, doctor sealed the soft areas from where the leak was most likely to occur. He found his right nostril wet and recently he got fluid discharge through his left nostril (nearly 8 drops). My question here is, would the leak sealed on the right side can recur in his left side? If so, should he go for another surgery or wait for it to heal by itself. He underwent a great pain in his previous surgery due to the lumbar drain and also find his head heavy as the exact place of leak was not sealed but had many layers of the tissues and muscles filled in the approximate place of leak. Please let us know what to do further.

  4. this was very well stated and easy to understand. I was diagnosed with IIH a few months ago. lots of questions and sad there are not more answers towards a cure

  5. No idea what my pressure was when i went into emergency surgery but after an ETV failure it spiked to 80, external shunt was turned back on. I developed chemical meningitus, white blood cell count was over 800. Couldn't do the shunt until it was under 30. Eye sight came back fully once the papilla edema went down. I got wonderful pictures of my wrinkly optic nerve.
    No answer to where the clog is in my ventricular system. I guess they said near the base of my neck. who knows, Onset: age 18.

  6. I have IIH diagnosed in early 2005. I was not over weight at that time of diagnoses though over the years I have gained weight I am however not in a morbid category. Treatments have included taps and diamox , am currently on diamox . At present the recommendation is VP shunting however I would like to avoid surgery and would like to know if I qualify for stenting?

  7. My wife is taking what they call a cocktail for the intercranial hypertension she is on a mix of meloxicam sumatriptan Tylenol and a benadryl

  8. I had brain surgery almost two years ago to remove a tumour. Since then I've had a build up of fluid in the brain around the site of surgery. Am waiting for quidance from my neuro surgeon. does anyone else know something about this?

  9. I just got diagnosed with IIH and my doctor never even mentioned weight loss. He just went straight to telling me I need a shunt. I’m so glad I saw this video, I’m going to ask him for other options because I heard that shunts can be really difficult

  10. In 2007 I experienced extreme sleep deprivation, hissing tinnitus & a possible CSF flush. My insides briefly lite up. It happened by itself, no drugs, no religious overtones except the image of a grasshopper in my minds eye right after. It might also have been a cockroach. After it happened I found an online animated illustration of the CSF ventricular system & the spinal chord. My brain was hitting reset to make up for what’s loosely referred to as insomnia.

  11. I remember getting a shot as a kid in my spine. because I remember my vision zooming in, with details on the wall you couldn't see till you stood and stared directly in front of it and things around me going really slow as I never knew what was happening. Something I cant explain today but remember vividly. Always happened suddenly, no pain no bad symptons, just not knowing what was happening and startled. I always ask my mom about that, she says she didn't know why I got the shot and says they misdiagnosed or mistreated me with it, I always ask about that time and she brushes it off, because they weren't supposed to give me that shot because they never really knew what was wrong at that time. The weird thing is before all that I remember slowly controlling it Everytime that happened, I'm still trying to search around what was the cause or what it is and I never had any mental problems or anything wrong mentally. Its kind of like getting used to sleep paralysis where your half asleep can't move but aware and see and hear your surroundings. You get use to being calm and slowly wake up easier and calmer. I don't know but it's something I can't stop thinking about. And I'm not talking about sleep paralysis, it's just an example on how I was kind of slowly not getting startled by it. No irrelevant or over exaggerated comments just some helpful ideas or articles about anything like it. I know it sounds weird as I remember and as you probably are reading this.

  12. I was frequently sick in childhood and to see my problem the doctors took out water from my back and now every now and then I get back pain its soo painful 😢😢😭.What should i do I showed it to doctor he prescribed some medicines still I get the pain soo hard its soo painfull 😢😢😭😭.

  13. Dr Luciano installed a shunt in my head last November. I never recovered vision in my right eye but I'm still alive.

  14. Does IIH cause balance problems; disequilibrium; feeling like falling down with no dizziness and no vertigo?

  15. I would love to show my brain MRI. All the doctors here in my small college town are perplexed. I was told that I may have had a massive stroke before birth. I was born in 1962 before MRIs. I was told my brain did not develop much but thanks to plasticity, my brain rewired itself and I graduated HS about a B- student. I do not drive because of low vision. A Neurosurgeon advised me not to be shunted this year when I saw a Neurosurgeon for the first time ever. I also have severe incontinence where I don’t leak, I gush using huge diapers every day. I was also diagnosed with Ankylosing Spondylitis about the same time my Incontinence developed along with IBD. I also have slight CP but never acknowledged by my Pediatrician or parents back in the day. Now I am scooter bound and peeing and in pain 24/7. My Urologist only wants to consider OAB as the reason why I am incontinent. I truly believe it is a spine/brain thing. I guess I’m stuck with this. My MRI of my brain is interesting if you’d like a picture of it

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