• World Neurosurg · Aug 2020

    Case Reports

    Transdural thoracic disc herniation with longitudinal slit-like dural defect causing intracranial hypotension. Report of two cases.

    • Erwin Cornips, Michelle Grouls, and Kim Bekelaar.
    • Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands. Electronic address: erwincornips@yahoo.com.
    • World Neurosurg. 2020 Aug 1; 140: e311-e319.

    BackgroundIntracranial hypotension (IH) has a widely variable clinical and radiologic presentation. Secondary IH may be caused by degenerative spine disorders and in particular by thoracic disk herniations (TDHs).MethodsWe present 2 patients with a transdural TDH, a secondary IH, and superficial siderosis in 1.ResultsCase 1 presented with headache, cognitive decline, staggering gait, bilateral subdural effusions, cerebral sagging, an extradural spinal cerebrospinal fluid (CSF) collection suggesting secondary IH, and a calcified TDH at T9-T10. Case 2 presented with intermittent pain at the craniocervical junction provoked exclusively by specific physical activities, superficial siderosis mainly in the posterior fossa, an extradural spinal CSF collection, and a calcified TDH at T7-T8 yet no intracranial signs of IH. In both cases, using strict thoracoscopic technique, we removed a transdural TDH and reconstructed an underlying longitudinal slitlike dural defect with smooth lining. Follow-up magnetic resonance imaging scans confirmed a dramatically improved situation without residual extradural intraspinal CSF collection or signs of IH.ConclusionsThis paper adds to the evidence that some cases of IH and even superficial siderosis are caused by transdural erosion of a TDH that may be otherwise asymptomatic. The dura may degenerate due to chronic compression, and a longitudinal slitlike dural defect with smooth lining may develop, causing continuous (Case 1) or intermittent (Case 2) intraspinal CSF leakage. To the best of our knowledge, such dural defects closely resembling the ones observed in idiopathic spinal cord herniation have never been demonstrated on intraoperative endoscopic video in IH patients.Copyright © 2020 Elsevier Inc. All rights reserved.

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