Overstijns Manou, El Rahal Amir, Wolf Katharina, Lützen Niklas, Würtemberger Urs, Becker Lucas, Urbach Horst, Martinez Daniel Casanova, Beck Jürgen, Volz Florian
Department of Neurosurgery, Medical Center University of Freiburg, Freiburg im Breisgau, Germany.
Department of Neuroradiology, Medical Center University of Freiburg, Freiburg im Breisgau, Germany.
Brain Spine. 2025 Jul 3;5:104320. doi: 10.1016/j.bas.2025.104320. eCollection 2025.
There is no accepted algorithm for the management of chronic subdural hematoma (cSDH) caused by spinal CSF leaks in spontaneous intracranial hypotension (SIH).
This study analyses characteristics of cSDH in SIH to establish a practicable management algorithm.
This retrospective cohort study included all patients with spinal CSF leak closure from April 2018 to April 2024. Demographics, leak type, treatment modalities, as well as cSDH characteristics, prevalence, and risk factors were analyzed.
Among 272 SIH patients, 85 (31 %) concomitantly had cSDH, predominantly bilateral (88 %). Hematoma width ranged from 2 to 30 mm. cSDH prevalence was highest in CSF-venous fistulas (43 %), followed by ventral (31 %) and lateral leaks (22 %). Male sex (OR = 4; p < 0.001) and age >70 years (OR = 6; p = 0.008) were significant risk factors. Surgical evacuation was performed in 23 patients, with symptoms attributable to cSDH in 17/23 patients. The biggest cSDH without surgical treatment was 20 mm. No neurological deterioration occurred during diagnostics or treatment of CSF leaks. After leak closure, no cSDH, regardless of initial size or previous treatment, required additional treatment, and no recurrence occurred in the 3-month follow-up.
Primary localization and targeted treatment of the spinal leak is safe in asymptomatic patients and cSDH ≤10 mm ("leak first" strategy). Immediate evacuation of the cSDH is mandatory in symptomatic patients ("subdural first" strategy). We consider the CSF leak closure as a causal treatment for cSDH resulting in a markedly low, close to zero, recurrence rate. Prospective validation of these findings is needed.
对于自发性颅内低压（SIH）所致脊髓脑脊液漏引起的慢性硬膜下血肿（cSDH），目前尚无公认的管理算法。
本研究分析SIH中cSDH的特征，以建立切实可行的管理算法。
这项回顾性队列研究纳入了2018年4月至2024年4月期间所有脊髓脑脊液漏闭合的患者。分析了人口统计学、漏口类型、治疗方式以及cSDH的特征、患病率和危险因素。
在272例SIH患者中，85例（31%）同时患有cSDH，主要为双侧（88%）。血肿宽度为2至30毫米。cSDH在脑脊液-静脉瘘中的患病率最高（43%），其次是腹侧漏口（31%）和侧方漏口（22%）。男性（OR = 4；p < 0.001）和年龄>70岁（OR = 6；p = 0.008）是显著的危险因素。23例患者接受了手术清除血肿，其中17/23例患者有cSDH相关症状。未经手术治疗的最大cSDH为20毫米。在脑脊液漏的诊断或治疗过程中未发生神经功能恶化。漏口闭合后，无论初始大小或先前治疗情况如何，cSDH均无需额外治疗，且在3个月的随访中无复发。
对于无症状患者和cSDH≤¹⁰毫米的患者，对脊髓漏进行初步定位和靶向治疗是安全的（“先处理漏口”策略）。对于有症状的患者，必须立即清除cSDH（“先处理硬膜下血肿”策略）。我们认为脑脊液漏闭合是cSDH的病因治疗，可使复发率显著降低，接近零。需要对这些发现进行前瞻性验证。
