Dilatation of the cerebral veins and venous sinuses may also selleck chemicals be a participatory mechanism and, in some situations, perhaps even the dominant mechanism. Some patients with stubborn orthostatic headaches, in recumbency, may report an earlier and a more effective relief in certain positions or postures, such as Trendelenburg position,[30] or by lying prone with the head dropped somewhat at the edge of the bed. It has been demonstrated that CSF OP is significantly higher in prone than in lateral decubitus position.[31] Headache, the most common clinical manifestation of spontaneous

CSF leaks, is often (although not always) associated with one or more of a variety of other manifestations listed in Table 2. Sometimes one or more of these may be the dominant clinical feature or, more rarely, the only clinical manifestation. Occasionally, headache may be completely absent. In the past two decades, increasing reports of various, and sometimes unexpected, manifestations

of spontaneous CSF leaks have appeared in the literature. Traction or compression Vincristine research buy is suspected to be the involved mechanism of various cranial nerve palsies in these patients. Cochleovestibular manifestations may result from traction or compression of the 8th cranial nerve or decrease in pressure of the perilymph, or both. Other manifestations have been similarly attributed to traction, compression, or displacement of various related structures including different lobes of the brain, brainstem or mesencephalon, pituitary stalk, or nerve roots.[32] Gait disorder and incontinence have been attributed by some researchers to spinal cord congestion. These attributions, however, are to be considered as proposed rather than proven mechanisms. In the early years

of MRI detection of pachymeningeal thickening, many patients were subjected to multiple CSF examinations in search of inflammatory, infectious, or neoplastic disease. Many lessons were learned including the substantial variability in the CSF findings in different patients with CSF leaks as well as in each individual MCE patient who had undergone multiple spinal taps on multiple occasions in the setting of symptomatic active CSF leaks. CSF OP is low in the large majority; but in a significant minority, perhaps in about one fourth of patients, it is within normal limits. The OP is uncommonly atmospheric and rarely is even negative. Color is often clear and only sometimes xanthochromic. Note that difficult and blood-tinged taps are not uncommon considering the very low pressure in some of the patients and presence of dilated epidural venous plexus in many (see spinal MRI findings and Table 4). Protein concentration may be normal or high. Values up to 100 mg/dL are not uncommon and concentrations as high as 1000 mg/dL have been reported.