Dr  Farnaz Amoozegar – Neurologist , C.H.A.M.P. – University of Calgary
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Dr Farnaz Amoozegar – Neurologist , C.H.A.M.P. – University of Calgary

September 2, 2019

Hello this is Dr. Farnaz Amoozegar, I’m a clinical assistant professor at the University of Calgary I’m also a
neurologist at the Calgary headache assessment and management program with a
subspecialty in headache and a special interest in sih or spontaneous
intracranial hypotension so today we’re going to do a short video discussing
what SIH is some of the things that we can do in terms of treatment as well as
workup for SIH and where you can access some resources so SIH or Spontaneous
Intracranial Hypotension is a term that’s used to describe a neurological
condition with a set of symptoms due to a Spinal CSF Leak that is usually
spontaneous however this can sometimes be due to minor trauma or it can be
because the underlying membrane where the CSF has held can be quite fragile in
some patients so CSF is Cerebral Spinal Fluid which is
the fluid that circulates around the brain and spine and overlying that is a
membrane called the dura and the dura is a thick membrane that protects the CSF
and sometimes what can happen is that a leak can occur within the dura or a hole
can occur within the dura and then CSF can start to flow out and that is what
leads to the symptoms patients with S I H will usually have a headache but they
can also have other symptoms like dizziness feeling off-balance having
trouble hearing for example or having a sensation that they’re underwater and
there can be many other symptoms as well so S I H can sometimes be difficult to
diagnose because because it can actually look quite similar to other headaches
like migraine or tension headache however there are some things that can
be helpful clues for us to determine that the headache is indeed S I H so S I H
are headaches that are classically worse when a patient is upright and they’re
generally better when a patient is laying down and that’s what we call
orthostatic headache or a postural headache because it changes with posture
whereas patients that have migraine or tension headache for example typically
won’t have that same orthostatic or postural association they may say that
they feel better when they lay down for example but that’s often because they’re
just resting and avoiding activity which tends to occur with migraine headaches
and that the headaches can worsen with activity but it’s still not that typical
postural orthostatic change the other thing is that patients with S I H can
some types of headaches that occur later in the day so often they’re fine in the
morning when they first wake up but in the afternoon or evening they start to
have a headache and the other thing is that migraine headaches tend to be
throbbing they usually worsen with activity and they’re associated with
light or sound sensitivity as well as nausea or vomiting which can happen with
S I H headaches but usually that’s not as prominent as migraine headaches and
these symptoms can occur with other headaches as well less commonly but
again it’s less common with S I H so tension headaches on the other hand are
usually milder headaches that affect both sides of the head and they’re like
a band like sensation around the head also patients that typically have S I H
start to have a headache that comes on over a number of days to weeks and then
it basically stays it doesn’t go away it’s a persistent headache typically it
may go away in the morning or when they lay down but it’s protected it’s
typically persistent whereas headaches like migraine or tension headache
usually there is a history preceding that a patient has had previous
episodes of that headache and then over time it may have become more chronic in
nature but typically it’s not a headache that just suddenly starts and then
persists so the first is that patients can try
conservative measures so first they can try for example to lay down as much as
possible for the first few days when they have the symptoms and drink lots of
fluids water as well as caffeine can be helpful and then see if that will help
solve the problem if it doesn’t then typically a scan of the brain is done
usually an MRI is a better test than a CT scan but if an MRI is not available a
CT scan is also still helpful if an MRI is done an MRI with contrast injection
is the best form of a test to do because it can show us signs of S I H that we
would not normally see sometimes with a plain MRI or with a CT scan but it’s
important to keep in mind that about 15 to 20 percent of patients can actually
have a normal MRI of the brain so it doesn’t rule out the diagnosis of S I H
but if the findings are there it certainly is helpful if sih remains the
strongest possibility despite a normal MRI if the clinical symptoms fit then a
blood patch can be done if the patient is still having symptoms usually this is
done in the lumbar area first because at that point the site of the leak is not
yet known so a blood patch is a procedure whereby a patient’s own blood
is taken out of a vein and reinjected into the lumbar area and that basically
acts like a glue to hold to seal over the leak and if the patient benefits
that’s great they can just be watched and followed but if there’s persistent
symptoms the blood patch may need to be repeated several times if that’s not
successful then more imaging is required and those images involve actually trying
to determine the exact site of a leak and these can be things like a
specialized CT scan that looks at the spine MRI scans that look for the spine
or other specialized tests so if the leak is found at a specific site based
on the testing that’s done then a directed blood patch can be done what
that means is that the blood patch can actually be done at the site where the
suspicion is based on the CT or MRI scan or other type of scan that’s done and
again that can be done sometimes up to a few times if needed if unfortunately
after that the patient still does not have success in terms of improvement of
their symptoms then other things can be done for example a glue type procedure
can be done at the site of the leak if the site of the leak is known or
potentially surgery if the patient has still
not had success with the treatments previously unfortunately sometimes
despite doing all of these investigations the site of the leak
cannot be found and in those cases we can go on then to use potential
medications to help with the symptoms so some of the different medications that
we might try we’d be medications that we may actually try and things like
migraine headache because there haven’t been really any studies to look at
specific medications for S I H in particular there are no clinical trials
or large research studies so some of the medications we would use for example
would be things like botulinum toxin injections that we might use in migraine
headache for example or medications that come from other classes that we use in
migraine for pain such as antidepressant medications blood pressure medications
or others the first step for the patient is to
speak his or her family doctor to discuss the
problem and if there is suspicion that the headache is not a typical migraine
or attention headache then the patient can be referred to a neurologist for
further assessment once the patient is seen by a neurologist typically a workup
is undertaken an appropriate treatment can be initiated if the patient’s case
is particularly challenging for example in terms of diagnosis or management then
the neurologists if they’re not a headache specialist can certainly
consider referring the patient to a headache specialist there are also
websites that can be useful resources for patients such as the one that you’re
on here the Spinal CSF Leak organization of Canada as well as the American Spinal
CSF Leak Foundation and others as well and that’s essentially the points we
wanted to cover today for the video we hope that you found it helpful www.spinalcsfleak.ca

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