Letters
tion as outlined in the National Comprehensive Cancer Network guidelines. However, in the event that this resection is not possible, radiotherapy and postradiation chemotherapy are recommended. The professional opinion of the neurosurgeons treating the patient presented in the article1 was that surgical resection for the ill-defined lesion would be difficult and could result in neurologic sequelae that would be unacceptable for the patient. After that decision was made, the clinical course of action was radiotherapy followed by chemotherapy and close follow-up. We were not involved in the clinical decision making for this patient’s case. About 2 years after diagnosis, serial monitoring by magnetic resonance imaging discovered a more discrete enhancing nodule near the initial biopsy site. This nodule was completely resected and the patient is doing well. We also agree that cerebellar mutism is mainly seen in pediatric cases with surgical resection of posterior fossa tumors. This article1 was not meant to review the characteristics of cerebellar mutism. The main concern was extension of the tumor into the brainstem that could have caused more serious consequences.
the following. In patients who have already developed a spontaneous (of whatever uncertain reason3) meningeal tear with subsequent CSF leak, the diagnostic lumbar puncture—to either demonstrate low pressure or to further identify the leak by infusing gadolinium intrathecally—could iatrogenically worsen the patient’s condition.3,4
James Battiste, MD, PhD Francy Shu, MD Steven Vernino, MD, PhD
3. Haritanti A, Karacostas D, Drevelengas A, et al. Spontaneous intracranial hypotension: clinical and neuroimaging findings in six cases with literature review. Eur J Radiol. 2009;69(2):253-259.
Author Affiliations: Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece. Corresponding Author: Dimitrios Parissis, PhD, Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, Thessaloniki, Greece ([email protected]). Conflict of Interest Disclosures: None reported. 1. Papadopoulou A, Ahlhelm F-J, Ulmer S, Kappos L, Sprenger T. Detection of cerebrospinal fluid leaks by intrathecal contrast-enhanced magnetic resonance myelography. JAMA Neurol. 2013;70(12):1576-1577. 2. Zeng Q, Xiong L, Jinkins JR, Fan Z, Liu Z. Intrathecal gadolinium-enhanced MR myelography and cisternography: a pilot study in human patients. AJR Am J Roentgenol. 1999;173(4):1109-1115.
4. Berroir S, Loisel B, Ducros A, et al. Early epidural blood patch in spontaneous intracranial hypotension. Neurology. 2004;63(10):1950-1951.
Author Affiliations: Peggy and Charles Stephenson Cancer Center, University of Oklahoma, Oklahoma City (Battiste); Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (Shu, Vernino). Corresponding Author: James Battiste, MD, PhD, Peggy and Charles Stephenson Cancer Center, University of Oklahoma, 800 NE 10th St, Oklahoma City, OK 73104 ([email protected]). Conflict of Interest Disclosures: None reported. Additional Information: The article1 was not intended to be an extensive review of treatment options for adult medulloblastoma but rather to highlight the importance of considering neoplastic processes in adult patients with neurologic symptoms localizing to the posterior fossa. 1. Shu F, Oberle R, Herndon E, Hatanpaa K, Battiste J, Vernino S. A rare adult cause of dizziness. JAMA Neurol. 2014;71(3):360-363.
Intrathecal Gadolinium for Magnetic Resonance Myelography in Spontaneous Intracranial Hypotension: Valuable But May Be Risky To the Editor In an article in JAMA Neurology, Papadopoulou et al1 demonstrated that intrathecal gadolinium–enhanced magnetic resonance (MR) myelography provided clear evidence of dural leaks along 2 lumbar roots in a case of spontaneous intracranial hypotension. Results from a previous radioisotope cisternography had been inconclusive in revealing these leaks, while an MR image of the spinal cord showed a small lumbar perineural cyst with no evidence of cerebrospinal fluid (CSF) leak.1 The authors concluded that the application of intrathecal gadolinium in MR myelography, as described by Zeng et al,2 although it is still an off-label use, may be a valuable alternative to radioisotope cisternography or computed tomographic myelography for the detection of spinal CSF leaks, avoiding ionizing radiation.1 Although we do not necessarily disagree with the authors’ conclusive concept, we nevertheless have to point out 802
Dimitrios Parissis, PhD Panos Ioannidis, PhD Dimitrios Karacostas, PhD
In Reply In their letter to the editor, Parissis et al correctly point out that intrathecal contrast-enhanced magnetic resonance myelography may have a negative impact on the symptoms of patients with spontaneous cerebrospinal fluid leaks and intracranial hypotension. It was beyond the scope of our brief article to provide a comprehensive in-depth review of the pros and cons of intrathecal contrast-enhanced magnetic resonance myelography or other methods to diagnose and treat spontaneous intracranial hypotension (SIH). Interestingly, based on available literature and our own experience, in SIH, worsening after a diagnostic spinal tap seems to be relatively infrequent, consists mostly of a slight increase of headache, and is typically of short duration.1-3 We assume that on the background of preexisting intracranial hypotension the leak produced by the diagnostic procedure does not make an important difference, especially if atraumatic needles are used.4,5 The possible adverse effects must be considered in relation to the therapeutic consequences, which may include targeted blood patches and, in rare cases, surgical intervention. Clearly, the diagnostic and therapeutic approach in patients with SIH needs to be individually tailored and discussed with the patient so that informed decisions can be taken, being aware that without informative controlled studies, there is no general consensus on best practice in this relatively rare condition. Athina Papadopoulou, MD Frank J. Ahlhelm, MD Till Sprenger, MD Author Affiliations: Department of Neurology, University Hospital Basel, Basel, Switzerland (Papadopoulou, Sprenger); Division of Diagnostic and
JAMA Neurology June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 06/04/2015
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Letters
Interventional Neuroradiology, Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland (Ahlhelm, Sprenger); Institute of Radiology, Department of Neuroradiology, Kantonsspital Baden AG, Baden, Switzerland (Ahlhelm). Corresponding Author: Till Sprenger, MD, Department of Neurology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland ([email protected]). Conflict of Interest Disclosures: Dr Papadopoulou has consulted for Teva and received travel support from Bayer AG and Teva in the last 3 years. Dr Sprenger has served on advisory boards for Genzyme, Teva, Novartis, Mitsubishi Pharma, Eli Lilly, Biogen Idec, and Allergan. He has received travel support from Genzyme, Pfizer, Bayer Schering, Eli Lilly, and Allergan. No other disclosures were reported. 1. Akbar JJ, Luetmer PH, Schwartz KM, Hunt CH, Diehn FE, Eckel LJ. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. AJNR Am J Neuroradiol. 2012;33(3):535-540. 2. Albes G, Weng H, Horvath D, Musahl C, Bäzner H, Henkes H. Detection and treatment of spinal CSF leaks in idiopathic intracranial hypotension. Neuroradiology. 2012;54(12):1367-1373. 3. Graff-Radford SB, Schievink WI. High-pressure headaches, low-pressure syndromes, and CSF leaks: diagnosis and management. Headache. 2014;54(2): 394-401. 4. Hammond ER, Wang Z, Bhulani N, McArthur JC, Levy M. Needle type and the risk of post-lumbar puncture headache in the outpatient neurology clinic. J Neurol Sci. 2011;306(1-2):24-28.
jamaneurology.com
5. Jones MJ, Selby IR, Gwinnutt CL, Hughes DG. Technical note: the influence of using an atraumatic needle on the incidence of post-myelography headache. Br J Radiol. 1994;67(796):396-398.
CORRECTION Incorrect Value in Table: In the Viewpoint titled “Disease Activity Free Status: A New End Point for a New Era in Multiple Sclerosis Clinical Research?” published online January 6, 2014, and in the March issue of JAMA Neurology (2014;71[3]: 269-270. doi:10.1001/jamaneurol.2013.5486), the Table contained a typographical error in the last column. The value for fingolimod in the composite clinical and radiographic disease activity free status should have been 33%. This article has been corrected online. Incorrect Information in Abstract: In the article titled “Correlation of Parkinson Disease Severity and 18F-DTBZ Positron Emission Tomography” published online April 21, 2014, and in the June issue of JAMA Neurology (2014;71[6]:758-766. doi:10.1001/jamaneurol.2014.290), incorrect information appeared. The second sentence of the Results section in the abstract should have read, “The mean reductions of vesicular monoamine transporter type 2 density for the caudate, putamen, and substantia nigra were 21.50%, 58.20%, and 21.10% for mild PD [Parkinson disease]; 60.75%, 79.49%, and 39.87% for moderate PD; and 63.94%, 83.20%, and 44.00% for advanced PD, respectively” instead of “The mean reductions of vesicular monoamine transporter type 2 density for the caudate, putamen, and substantia nigra were 27.29%, 63.26%, and 31.03% for mild PD; 61.76%, 81.54%, and 48.41% for moderate PD; and 81.78%, 89.47%, and 66.62% for advanced PD, respectively.” This article was corrected online.
JAMA Neurology June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 06/04/2015
803
tion as outlined in the National Comprehensive Cancer Network guidelines. However, in the event that this resection is not possible, radiotherapy and postradiation chemotherapy are recommended. The professional opinion of the neurosurgeons treating the patient presented in the article1 was that surgical resection for the ill-defined lesion would be difficult and could result in neurologic sequelae that would be unacceptable for the patient. After that decision was made, the clinical course of action was radiotherapy followed by chemotherapy and close follow-up. We were not involved in the clinical decision making for this patient’s case. About 2 years after diagnosis, serial monitoring by magnetic resonance imaging discovered a more discrete enhancing nodule near the initial biopsy site. This nodule was completely resected and the patient is doing well. We also agree that cerebellar mutism is mainly seen in pediatric cases with surgical resection of posterior fossa tumors. This article1 was not meant to review the characteristics of cerebellar mutism. The main concern was extension of the tumor into the brainstem that could have caused more serious consequences.
the following. In patients who have already developed a spontaneous (of whatever uncertain reason3) meningeal tear with subsequent CSF leak, the diagnostic lumbar puncture—to either demonstrate low pressure or to further identify the leak by infusing gadolinium intrathecally—could iatrogenically worsen the patient’s condition.3,4
James Battiste, MD, PhD Francy Shu, MD Steven Vernino, MD, PhD
3. Haritanti A, Karacostas D, Drevelengas A, et al. Spontaneous intracranial hypotension: clinical and neuroimaging findings in six cases with literature review. Eur J Radiol. 2009;69(2):253-259.
Author Affiliations: Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece. Corresponding Author: Dimitrios Parissis, PhD, Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, Thessaloniki, Greece ([email protected]). Conflict of Interest Disclosures: None reported. 1. Papadopoulou A, Ahlhelm F-J, Ulmer S, Kappos L, Sprenger T. Detection of cerebrospinal fluid leaks by intrathecal contrast-enhanced magnetic resonance myelography. JAMA Neurol. 2013;70(12):1576-1577. 2. Zeng Q, Xiong L, Jinkins JR, Fan Z, Liu Z. Intrathecal gadolinium-enhanced MR myelography and cisternography: a pilot study in human patients. AJR Am J Roentgenol. 1999;173(4):1109-1115.
4. Berroir S, Loisel B, Ducros A, et al. Early epidural blood patch in spontaneous intracranial hypotension. Neurology. 2004;63(10):1950-1951.
Author Affiliations: Peggy and Charles Stephenson Cancer Center, University of Oklahoma, Oklahoma City (Battiste); Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (Shu, Vernino). Corresponding Author: James Battiste, MD, PhD, Peggy and Charles Stephenson Cancer Center, University of Oklahoma, 800 NE 10th St, Oklahoma City, OK 73104 ([email protected]). Conflict of Interest Disclosures: None reported. Additional Information: The article1 was not intended to be an extensive review of treatment options for adult medulloblastoma but rather to highlight the importance of considering neoplastic processes in adult patients with neurologic symptoms localizing to the posterior fossa. 1. Shu F, Oberle R, Herndon E, Hatanpaa K, Battiste J, Vernino S. A rare adult cause of dizziness. JAMA Neurol. 2014;71(3):360-363.
Intrathecal Gadolinium for Magnetic Resonance Myelography in Spontaneous Intracranial Hypotension: Valuable But May Be Risky To the Editor In an article in JAMA Neurology, Papadopoulou et al1 demonstrated that intrathecal gadolinium–enhanced magnetic resonance (MR) myelography provided clear evidence of dural leaks along 2 lumbar roots in a case of spontaneous intracranial hypotension. Results from a previous radioisotope cisternography had been inconclusive in revealing these leaks, while an MR image of the spinal cord showed a small lumbar perineural cyst with no evidence of cerebrospinal fluid (CSF) leak.1 The authors concluded that the application of intrathecal gadolinium in MR myelography, as described by Zeng et al,2 although it is still an off-label use, may be a valuable alternative to radioisotope cisternography or computed tomographic myelography for the detection of spinal CSF leaks, avoiding ionizing radiation.1 Although we do not necessarily disagree with the authors’ conclusive concept, we nevertheless have to point out 802
Dimitrios Parissis, PhD Panos Ioannidis, PhD Dimitrios Karacostas, PhD
In Reply In their letter to the editor, Parissis et al correctly point out that intrathecal contrast-enhanced magnetic resonance myelography may have a negative impact on the symptoms of patients with spontaneous cerebrospinal fluid leaks and intracranial hypotension. It was beyond the scope of our brief article to provide a comprehensive in-depth review of the pros and cons of intrathecal contrast-enhanced magnetic resonance myelography or other methods to diagnose and treat spontaneous intracranial hypotension (SIH). Interestingly, based on available literature and our own experience, in SIH, worsening after a diagnostic spinal tap seems to be relatively infrequent, consists mostly of a slight increase of headache, and is typically of short duration.1-3 We assume that on the background of preexisting intracranial hypotension the leak produced by the diagnostic procedure does not make an important difference, especially if atraumatic needles are used.4,5 The possible adverse effects must be considered in relation to the therapeutic consequences, which may include targeted blood patches and, in rare cases, surgical intervention. Clearly, the diagnostic and therapeutic approach in patients with SIH needs to be individually tailored and discussed with the patient so that informed decisions can be taken, being aware that without informative controlled studies, there is no general consensus on best practice in this relatively rare condition. Athina Papadopoulou, MD Frank J. Ahlhelm, MD Till Sprenger, MD Author Affiliations: Department of Neurology, University Hospital Basel, Basel, Switzerland (Papadopoulou, Sprenger); Division of Diagnostic and
JAMA Neurology June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 06/04/2015
jamaneurology.com
Letters
Interventional Neuroradiology, Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland (Ahlhelm, Sprenger); Institute of Radiology, Department of Neuroradiology, Kantonsspital Baden AG, Baden, Switzerland (Ahlhelm). Corresponding Author: Till Sprenger, MD, Department of Neurology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland ([email protected]). Conflict of Interest Disclosures: Dr Papadopoulou has consulted for Teva and received travel support from Bayer AG and Teva in the last 3 years. Dr Sprenger has served on advisory boards for Genzyme, Teva, Novartis, Mitsubishi Pharma, Eli Lilly, Biogen Idec, and Allergan. He has received travel support from Genzyme, Pfizer, Bayer Schering, Eli Lilly, and Allergan. No other disclosures were reported. 1. Akbar JJ, Luetmer PH, Schwartz KM, Hunt CH, Diehn FE, Eckel LJ. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. AJNR Am J Neuroradiol. 2012;33(3):535-540. 2. Albes G, Weng H, Horvath D, Musahl C, Bäzner H, Henkes H. Detection and treatment of spinal CSF leaks in idiopathic intracranial hypotension. Neuroradiology. 2012;54(12):1367-1373. 3. Graff-Radford SB, Schievink WI. High-pressure headaches, low-pressure syndromes, and CSF leaks: diagnosis and management. Headache. 2014;54(2): 394-401. 4. Hammond ER, Wang Z, Bhulani N, McArthur JC, Levy M. Needle type and the risk of post-lumbar puncture headache in the outpatient neurology clinic. J Neurol Sci. 2011;306(1-2):24-28.
jamaneurology.com
5. Jones MJ, Selby IR, Gwinnutt CL, Hughes DG. Technical note: the influence of using an atraumatic needle on the incidence of post-myelography headache. Br J Radiol. 1994;67(796):396-398.
CORRECTION Incorrect Value in Table: In the Viewpoint titled “Disease Activity Free Status: A New End Point for a New Era in Multiple Sclerosis Clinical Research?” published online January 6, 2014, and in the March issue of JAMA Neurology (2014;71[3]: 269-270. doi:10.1001/jamaneurol.2013.5486), the Table contained a typographical error in the last column. The value for fingolimod in the composite clinical and radiographic disease activity free status should have been 33%. This article has been corrected online. Incorrect Information in Abstract: In the article titled “Correlation of Parkinson Disease Severity and 18F-DTBZ Positron Emission Tomography” published online April 21, 2014, and in the June issue of JAMA Neurology (2014;71[6]:758-766. doi:10.1001/jamaneurol.2014.290), incorrect information appeared. The second sentence of the Results section in the abstract should have read, “The mean reductions of vesicular monoamine transporter type 2 density for the caudate, putamen, and substantia nigra were 21.50%, 58.20%, and 21.10% for mild PD [Parkinson disease]; 60.75%, 79.49%, and 39.87% for moderate PD; and 63.94%, 83.20%, and 44.00% for advanced PD, respectively” instead of “The mean reductions of vesicular monoamine transporter type 2 density for the caudate, putamen, and substantia nigra were 27.29%, 63.26%, and 31.03% for mild PD; 61.76%, 81.54%, and 48.41% for moderate PD; and 81.78%, 89.47%, and 66.62% for advanced PD, respectively.” This article was corrected online.
JAMA Neurology June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 06/04/2015
803
