1. ASNR 53rd Annual Meeting – Poster EP-39, Control # 1239
Arterial Spin Labeled Brain Perfusion in Patients with Disorders of Intracranial Pressure: A Prospective Study of Changes Related to Measured Cerebrospinal Fluid Pressure
ASNR 53rd Annual Meeting – Poster EP-39, Control # 1239
Amit M. Saindane, M.D.
Deqiang Qiu, Ph.D.
John F. Holbrook, M.D.
John Oshinski, Ph.D.
Department of Radiology and Imaging Sciences
Emory University School of Medicine

2. The authors have no relevant disclosures.

3. Background: Idiopathic Intracranial Hypertension (IIH)
Syndrome with elevated intracranial pressure (ICP) without identifiable cause
Associated orbital and skull base MRI findings
Friedman DI et al. Neurology. 2002;59:

4. Background: Spontaneous Intracranial Hypotension (SIH)
Orthostatic headaches with low ICP due to CSF leak
Associated imaging signs of “brain sag”

5. Background:
ICP estimated through lumbar puncture (LP) and CSF manometry to measure an opening pressure (OP).
If OP elevated, therapeutic CSF removal performed to decrease ICP, with a closing pressure (CP) checked.
If clinical diagnosis of SIH (generally will have low OP), therapeutic epidural blood patch may be performed to increase ICP.
L.S.

6. Purpose:
To assess changes in arterial spin labeled (ASL) brain perfusion following lumbar puncture with CSF removal in patients with know or suspected disorders of ICP (IIH and SIH).

7. Methods: Patients IRB Approved prospective study
5 women with known/suspected ICP disorders
2 with known diagnosis of IIH under treatment
2 with suspected IIH
1 with suspected SIH

8. Methods: Patient Protocol
Therapeutic
CSF Removal and CP Measurement
n=4
<15 min
MRI Part 2
(with ASL Perfusion)
<15 min
LP with OP Measurement
MRI Part 1
(with ASL Perfusion)
Therapeutic
Epidural
Blood Patch
n=1
2 hours
MRI Part 2
(with ASL Perfusion)

9. Methods: MR Imaging 3.0-T Siemens Trio MRI Unit 3D GRASE ASL sequence
Whole brain mean cerebral blood flow (CBF) calculated

10. Results: Known/Suspected IIH
Patients 1 and 2 with known medically treated IIH had normal OP
Patients 3 and 4 with suspected IIH had elevated OP
OP (cm water)
CSF
Removed (ml)
CP (cm water)
Pre-LP CBF
(ml/100g/min)
Post-LP CBF
% Change from Baseline
Patient 1 13 11 12
35.6
33.6
-5.6%
Patient 2 16 7
46.3
43.6
-5.8%
Patient 3 35 14 20
29.1
31.1
+6.9%
Patient 4 26
47.4
47.7
+0.6%

11. Results: SIH Patient Patient 5 met diagnostic criteria for SIH
OP=14.5 cm water. No CSF withdrawn. CP not measured.
CBF increased from 34.2 ml/100g/min to 43.9 ml/100g/min (28%) following blood patch with resolution of positional headaches.

12. Limitations Small number of patients.
Closing pressure not available for SIH patient.
Medical treatment of IIH patients may impact effect of CSF removal on CBF.
Optimal timing for post-LP MRI is unknown. It may take greater time for brain CBF to adapt to removal of CSF.

13. Conclusions
In IIH patients immediately following LP and CSF removal, there is not a substantial change in brain CBF. This may reflect chronic adaptation to high ICP or insufficient time for the CBF to re- equilibrate after LP and CSF removal
In one SIH patient 2 hours following therapeutic epidural blood patching, we observed an large (28%) increase in CBF.