title: Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients.
abstract: OBJECTIVE
  The etiology of chronic subdural hematoma (CSDH) in nongeriatric patients (≤ 60 years old) often remains unclear. The primary objective of this study was to identify spinal CSF leaks in young patients, after formulating the hypothesis that spinal CSF leaks are causally related to CSDH.
  
  
  METHODS
  All consecutive patients 60 years of age or younger who underwent operations for CSDH between September 2009 and April 2011 at Bern University Hospital were included in this prospective cohort study. The patient workup included an extended search for a spinal CSF leak using a systematic algorithm: MRI of the spinal axis with or without intrathecal contrast application, myelography/fluoroscopy, and postmyelography CT. Spinal pathologies were classified according to direct proof of CSF outflow from the intrathecal to the extrathecal space, presence of extrathecal fluid accumulation, presence of spinal meningeal cysts, or no pathological findings. The primary outcome was proof of a CSF leak.
  
  
  RESULTS
  Twenty-seven patients, with a mean age of 49.6 ± 9.2 years, underwent operations for CSDH. Hematomas were unilateral in 20 patients and bilateral in 7 patients. In 7 (25.9%) of 27 patients, spinal CSF leakage was proven, in 9 patients (33.3%) spinal meningeal cysts in the cervicothoracic region were found, and 3 patients (11.1%) had spinal cysts in the sacral region. The remaining 8 patients (29.6%) showed no pathological findings.
  
  
  CONCLUSIONS
  The direct proof of spinal CSF leakage in 25.9% of patients suggests that spinal CSF leaks may be a frequent cause of nongeriatric CSDH.
authors.affiliation: Departments of Neurosurgery.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Beck
authors.forename: Jan
authors.initials: J
authors.lastname: Gralla
authors.forename: Christian
authors.initials: C
authors.lastname: Fung
authors.forename: Christian T
authors.initials: CT
authors.lastname: Ulrich
authors.forename: Philippe
authors.initials: P
authors.lastname: Schucht
authors.forename: Jens
authors.initials: J
authors.lastname: Fichtner
authors.forename: Lukas
authors.initials: L
authors.lastname: Andereggen
authors.forename: Martin
authors.initials: M
authors.lastname: Gosau
authors.forename: Elke
authors.initials: E
authors.lastname: Hattingen
authors.forename: Klemens
authors.initials: K
authors.lastname: Gutbrod
authors.forename: Werner J
authors.initials: WJ
authors.lastname: Z'Graggen
authors.forename: Michael
authors.initials: M
authors.lastname: Reinert
authors.forename: Jürg
authors.initials: J
authors.lastname: Hüsler
authors.forename: Christoph
authors.initials: C
authors.lastname: Ozdoba
authors.forename: Andreas
authors.initials: A
authors.lastname: Raabe
mesh_terms: D000328:Adult; D000367:Age Factors; D000465:Algorithms; D065634:Cerebrospinal Fluid Leak / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D005260:Female; D005471:Fluoroscopy; D020200:Hematoma, Subdural, Chronic / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D006801:Humans; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009192:Myelography; D011446:Prospective Studies; D013116:Spinal Cord / Q000000981:diagnostic imaging / Q000473:pathology; D013118:Spinal Cord Diseases / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D014057:Tomography, X-Ray Computed
keywords: CSDH = chronic subdural hematoma; SIH = spontaneous intracranial hypotension; SPACE = sampling perfection with application of optimized contrasts using different flip angle evolutions; chronic subdural hematoma; geriatric; mRS = modified Rankin Scale; meningeal cyst; spinal CSF leak; vascular disorders