{"title":"Radiographic Evaluation of Spontaneous Intracranial Hypotension.","authors":"Ajay A Madhavan, J Levi Chazen","doi":"10.1212/CON.0000000000001567","DOIUrl":"https://doi.org/10.1212/CON.0000000000001567","url":null,"abstract":"<p><strong>Objective: </strong>Diagnostic imaging evaluation for patients with suspected spontaneous intracranial hypotension has evolved substantially in recent years. This article describes a practical algorithm for radiographic diagnosis of spontaneous intracranial hypotension and localization of spinal CSF leaks.</p><p><strong>Latest developments: </strong>Brain and spine MRI is the mainstay of the initial diagnostic workup of patients with spontaneous intracranial hypotension. Recently, sophisticated myelographic techniques to precisely subtype and localize CSF leaks have been developed and refined. These include fluoroscopic techniques, such as digital subtraction myelography, and CT-based techniques, such as hyperdynamic CT myelography. These techniques improve the detection of various types of CSF leaks, thereby enabling targeted therapies.</p><p><strong>Essential points: </strong>Neurologists should familiarize themselves with the variety of imaging necessary to initially support a diagnosis of spontaneous intracranial hypotension and the myelographic techniques needed to precisely localize spinal CSF leaks.</p>","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"668-687"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210170","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Treatment of Spinal CSF Leaks and Fistulas.","authors":"Narayan R Kissoon, Thien J Huynh","doi":"10.1212/CON.0000000000001568","DOIUrl":"https://doi.org/10.1212/CON.0000000000001568","url":null,"abstract":"<p><strong>Objective: </strong>The options for treatment of spontaneous spinal CSF leaks and CSF-venous fistulas have expanded in recent years, and this article reviews the current treatments available, factors that affect treatment outcomes, and an algorithmic approach to treatment.</p><p><strong>Latest developments: </strong>Until recently, treatments for spontaneous intracranial hypotension consisted of supportive care, epidural blood patching, and when the site of CSF leakage was known, surgical repair. CSF-venous fistulas are now known to be common causes of CSF hypotension and are rarely cured by epidural blood patching. Better visualization of CSF-venous fistulas and the novel treatment of CSF-venous fistulas with transvenous embolization have expanded the arsenal of treatment options for spontaneous intracranial hypotension.</p><p><strong>Essential points: </strong>Clinical outcomes improve with timely treatment of spinal CSF leaks and CSF-venous fistulas. Radiographic features direct treatment, which includes epidural blood patching, transvenous embolization, and surgical correction. CSF-venous fistulas respond poorly to epidural blood patching but can respond favorably to surgical obliteration or transvenous embolization.</p>","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"688-708"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Treatment and Monitoring of Idiopathic Intracranial Hypertension.","authors":"John J Chen, Susan P Mollan","doi":"10.1212/cont.0000000000001586","DOIUrl":"https://doi.org/10.1212/cont.0000000000001586","url":null,"abstract":"<p><strong>Objective: </strong>This article reviews the management of idiopathic intracranial hypertension (IIH), which is essential to neurology practice.</p><p><strong>Latest developments: </strong>The incidence and prevalence of IIH have risen because of the worldwide obesity epidemic. Evidence suggests that IIH has a unique systemic metabolic phenotype. Clinical history, examination, and visual fields remain the cornerstone for monitoring people with IIH. Optical coherence tomography demonstrates structural changes that aid decision-making. The principles of IIH management include protecting vision and escalating to surgical interventions when it is threatened, addressing the role of obesity in the condition, and providing advice on headache therapeutics. There are no labeled therapies for IIH; however, acetazolamide remains the most common medication prescribed. A glucagon-like peptide-1 receptor agonist was recently shown to reduce intracranial pressure independent of weight reduction in a phase II randomized controlled trial in people with IIH, suggesting it could be a promising treatment for IIH. In patients with IIH requiring surgery, there has been an increase in venous sinus stenting.</p><p><strong>Essential points: </strong>Neurologists are central in the management pathway for people with IIH. Ongoing coordinated care between ophthalmologists and neurologists is essential for optimal care of these patients.</p>","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"728-756"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210173","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Key Points for Issue.","authors":"","doi":"10.1212/01.cont.0001118136.28649.d7","DOIUrl":"https://doi.org/10.1212/01.cont.0001118136.28649.d7","url":null,"abstract":"","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210165","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"A New Specialty Under Pressure.","authors":"Lyell K Jones","doi":"10.1212/cont.0000000000001610","DOIUrl":"https://doi.org/10.1212/cont.0000000000001610","url":null,"abstract":"","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"642-643"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Atraumatic Cranial CSF Leaks.","authors":"Erin K O'Brien, Maria Peris Celda","doi":"10.1212/CON.0000000000001571","DOIUrl":"https://doi.org/10.1212/CON.0000000000001571","url":null,"abstract":"<p><strong>Objective: </strong>This article reviews the most common presenting symptoms and radiographic findings of atraumatic cranial CSF leaks, surgical management of skull base leaks, and postoperative management of idiopathic intracranial hypertension (IIH).</p><p><strong>Latest developments: </strong>IIH is now widely accepted as a causative factor in the development of thinning of the bone of the anterior and lateral skull base and formation of encephaloceles or arachnoid granulations through the skull base with resulting CSF leaks into the aerated sinuses or middle ear and mastoid cavities. Demographic characteristics and presenting symptoms may differ slightly between patients with IIH and those with CSF leaks, but in both populations, management of elevated intracranial CSF pressure is required. Dural venous stenosis is associated with both conditions, and stenting of transverse or sigmoid sinus stenotic segments is now considered a treatment option for IIH.</p><p><strong>Essential points: </strong>Atraumatic cranial CSF leaks present with clear fluid either dripping from the nose or accumulating in the middle ear and mastoid because of bony and dural defects in the anterior or lateral skull base. Cranial CSF leaks are often associated with IIH, and treatment requires both repair of the skull base defects and management of IIH. Timely diagnosis and treatment of CSF leaks and IIH are necessary to prevent meningitis and decrease the risk of recurrence of leaks or sequelae of IIH. Patients with these CSF leaks should be evaluated for IIH by imaging or postoperative lumbar puncture with opening pressure because pressure may increase further once the CSF leak is repaired. Medication, weight loss, and CSF shunting are management options for elevated CSF pressure, but imaging for intracranial venous stenosis should be considered with venous stenting for treatment of elevated venous pressure.</p>","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"757-768"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210157","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Childhood-onset Hydrocephalus.","authors":"Shenandoah Robinson","doi":"10.1212/cont.0000000000001578","DOIUrl":"https://doi.org/10.1212/cont.0000000000001578","url":null,"abstract":"<p><strong>Objective: </strong>This article highlights important concepts of caring for patients with childhood-onset hydrocephalus across the lifespan, emphasizing recent advances and current areas of controversy.</p><p><strong>Latest developments: </strong>There are numerous causes of symptomatic hydrocephalus in neonates, infants, and children, and each etiology predicts the typical clinical course across the lifespan. Because the major cellular components essential for CSF dynamics develop predominantly during the third trimester and first 6 months after term birth, directly overlapping with the onset of many types of fetal, neonatal, and infantile hydrocephalus, the timing of onset impacts lifelong management. The treatment of childhood-onset hydrocephalus varies dramatically worldwide due to the differing etiologies and access to neurosurgical interventions. The surgical options for CSF diversion have advanced over the past decade, with a better appreciation of which techniques are more successful for the various types of childhood-onset hydrocephalus. These advances include using temporary shunt devices to delay permanent CSF diversion and endoscopic third ventriculostomy, at times with choroid plexus cauterization.</p><p><strong>Essential points: </strong>Etiology and age of onset impact the lifelong management of individuals living with childhood-onset hydrocephalus, with a rapid pace of evidence-based changes in clinical practice.</p>","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"850-864"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210159","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Management of Normal Pressure Hydrocephalus.","authors":"Kaisorn L Chaichana, Jeremy K Cutsforth-Gregory","doi":"10.1212/CON.0000000000001569","DOIUrl":"https://doi.org/10.1212/CON.0000000000001569","url":null,"abstract":"<p><strong>Objective: </strong>This article reviews the preoperative considerations, postoperative complications, and ongoing management of shunts for normal pressure hydrocephalus.</p><p><strong>Latest developments: </strong>The radiographic pattern of disproportionately enlarged subarachnoid space hydrocephalus (DESH) predicts a positive response to permanent CSF diversion. MRI-safe programmable shunt valves allow for fluid drainage adjustment based on patients' symptoms and radiographic images. Endoscopic third ventriculostomy is a viable alternative to shunting for patients with normal pressure hydrocephalus due to aqueductal stenosis.</p><p><strong>Essential points: </strong>Approximately 75% of patients with normal pressure hydrocephalus improve after shunt surgery regardless of shunt type or location. Clinical benefit and complication rates are similar for frontal and parietal ventricular catheter approaches. Acetazolamide is not an effective treatment for normal pressure hydrocephalus.</p>","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"840-849"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Table of Contents.","authors":"","doi":"10.1212/cont.0000000000001581","DOIUrl":"https://doi.org/10.1212/cont.0000000000001581","url":null,"abstract":"","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"632-633"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210172","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Treatment of Persistent Headache After Normalization of CSF Pressure.","authors":"Olga Fermo","doi":"10.1212/CON.0000000000001573","DOIUrl":"https://doi.org/10.1212/CON.0000000000001573","url":null,"abstract":"<p><strong>Objective: </strong>Headache is the most common symptom of intracranial hypertension and hypotension and may not remit after normalization of intracranial pressure. This article reviews the clinical presentation, mechanism, differential diagnosis, treatment, prognosis, and monitoring of persistent headache after normalization of intracranial pressure in the setting of idiopathic intracranial hypertension and spontaneous intracranial hypotension.</p><p><strong>Latest developments: </strong>Erenumab, a monoclonal antibody to the calcitonin gene-related peptide receptor, was shown to reduce headache frequency in the first-ever prospective study of headache treatment in patients with idiopathic intracranial hypertension in ocular remission. Similar avenues remain to be explored for spontaneous intracranial hypotension even though it has been shown that some patients continue with headache despite radiographic resolution of CSF leaks.</p><p><strong>Essential points: </strong>Headache is the most common symptom to herald an intracranial pressure disturbance and may not resolve despite normalization of pressure. Neurologists must be aware that persistent headache does not automatically imply abnormal intracranial pressure in patients with previous disorders of CSF dynamics and informed of the possible alternative headache etiologies in these populations.</p>","PeriodicalId":52475,"journal":{"name":"CONTINUUM Lifelong Learning in Neurology","volume":"31 3","pages":"769-789"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210174","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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