Cerebrospinal fluid is the clear fluid that surrounds the brain and spinal cord. It cushions the brain and spinal cord from injury, delivers nutrients and acts as a waste removal system for the brain.

A cerebrospinal fluid leak occurs when fluid escapes through a small tear or hole in the outermost layer of tissue that surrounds the brain or the spinal cord. Leaks can occur in the skull or at any point along the spinal column.

Because headache is a common symptom, patients are often misdiagnosed or mistreated for migraines.

"About 85% of patients with a cerebrospinal fluid leak at the level of the spine will have an orthostatic headache — one that gets worse when they stand up and better when they lie down," says Dr. Jeremy Cutsforth-Gregory, a Mayo Clinic neurologist.

Once properly diagnosed, a blood patch procedure is often an effective treatment for spinal cerebrospinal fluid leaks. The patient's own blood is injected into the spinal canal, and the blood clot that forms can stop the leak. In other patients, surgery or a novel procedure called paraspinal vein embolization may be more appropriate.

On the Mayo Clinic Q&A podcast, Dr. Cutsforth-Gregory discusses diagnosing and treating spinal cerebrospinal spinal fluid leaks.

Watch: Dr. Cutsforth-Gregory discuss treatment for spinal cerebral spinal fluid leaks

Read the full transcript.

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For the safety of its patients, staff and visitors, Mayo Clinic has strict masking policies in place. Anyone shown without a mask was either recorded prior to COVID-19 or recorded in a nonpatient care area where social distancing and other safety protocols were followed.

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Diagnosis and treatment of normal pressure hydrocephalus for Robert Richter meant the difference between being confined to a wheelchair and being able to actively enjoy his life.

Members of Robert Richter's extended family were excited to see him on his feet and walking unassisted at the annual family picnic in early August.

"They went through Bob's downhill slide and not knowing what was going on with him right along with us," says Kathleen Richter, Bob's wife of 50 years. "Everyone was delighted to see him doing so well."

Bob's slide began last fall when the 74-year old Minneapolis resident was having trouble walking and getting up from a chair. He also had problems with his balance.

A local neurologist diagnosed Bob with spinal cord compression, also called spinal stenosis, and he had cervical spine surgery in November 2017. After that, his family was confident he would get better. But within a month, Bob was walking with a cane and, shortly thereafter, a walker. By January, Bob was confined to a wheelchair, no longer able to walk on his own. The decline was upsetting, and the couple wasn't sure what to do. They decided they needed another medical opinion.

"We didn't know what to make of it, and then you start to think, 'Do we move from our 100-year old house, which has a bathroom upstairs? Do we need assisted living?'" Kathleen says. "My family had had many good experiences at Mayo Clinic in Rochester, so we went there."

Another culprit

At Mayo Clinic, Bob saw neurologist Christopher Boes, M.D., and neurology resident Shannon Chiu, M.D. He also was evaluated at Mayo's Cerebrospinal Fluid Dynamic Center, staffed by neurologists David Jones, M.D., Jonathan Graff-Radford, M.D., and Jeremy Cutsforth-Gregory, M.D.

After careful evaluation, Bob's care team was able to identify the source of his disability. In addition to the spinal stenosis, there was another underlying problem. A brain MRI revealed the fluid-filled chambers, or ventricles, in Bob's brain were enlarged due to an accumulation of extra cerebrospinal fluid. The care team performed a high-volume spinal tap to drain the fluid. They then confirmed a diagnosis of normal pressure hydrocephalus. Although the fluid pressure in Bob's brain was normal, the enlarged ventricles were disrupting nearby brain tissue and affecting his brain function.

After Bob's diagnosis, his care team referred him to Mayo Clinic neurosurgeon Benjamin Elder, M.D., Ph.D. According to Dr. Elder, there are no clear risk factors for normal pressure hydrocephalus. The median age at diagnosis is the mid-70s.

"There are studies that suggest normal pressure hydrocephalus affects up to 3 percent of people above age 65."

Benjamin Elder, M.D., Ph.D.

"No one knows what causes it, but it's thought to be the result of an obstruction somewhere along the passage ways of the brain that drain cerebrospinal fluid," Dr. Elder says. "There are studies that suggest normal pressure hydrocephalus affects up to 3 percent of people above age 65."

The disorder is characterized by a triad of symptoms, including issues with gait, cognitive abnormalities, such as short-term memory loss, and urinary incontinence.

"About 70 percent of patients have all three of these symptoms, and 85 percent have two," Dr. Elder says.

For many people who have normal pressure hydrocephalus, treatment is available. In Bob's case, a surgical procedure could help relieve his symptoms.

"If the patient sees improvement from the high-volume spinal tap, then he or she is potentially a candidate for implanting a ventriculoperitoneal shunt in the brain to drain the fluid," Dr. Elder says. "There is about an 80 percent chance of improvement after shunting, particularly with gait problems."

A complete turnaround

Bob had an hour-long surgery to place the shunt on March 5. The procedure involves drilling a hole in the skull about the size of a dime and placing a rubber tube through the brain into the space where the spinal fluid circulates.

"That tube connects to a valve sitting behind the ear, which regulates the flow of spinal fluid and is connected to another rubber tube that runs down to the abdomen and drains the fluid into the peritoneum, the smooth, transparent membrane that lines the cavity of the abdomen," Dr. Elder says. "The body then reabsorbs all the extra fluid."

After surgery, Bob had six weeks of inpatient and outpatient rehabilitation, as well as occupational therapy. His transformation during that time was extraordinary for the Richters.

"We saw changes right away. Now he can walk the dog with me, and we can go out into the world. It's a complete turnaround," Kathleen says. "We didn't know what we were dealing with because no one seemed to have an answer. Getting those answers and having such a wonderful recovery … for us, it's a miracle."

According to Dr. Elder, Bob's situation isn't uncommon. Normal pressure hydrocephalus often goes undiagnosed. Some patients are even told that they have a condition like Alzheimer's disease or Parkinson's disease, which is later found to be normal pressure hydrocephalus.

"We didn't know what we were dealing with because no one seemed to have an answer. Getting those answers and having such a wonderful recovery … for us, it's a miracle."

Kathleen Richter

"That's why it's critical for primary care providers and neurologists to consider normal pressure hydrocephalus as a possible diagnosis," Dr. Elder says. "Many patients report symptoms for more than two years before receiving a diagnosis, and they can be so debilitated during that time. You need to look at the MRI and special cognitive testing that neurologists or neuropsychologists perform. If a patient has the cognitive issues but not gait issues, they likely don't have hydrocephalus."

Bob’s case was complicated by the fact that he had spinal stenosis and hydrocephalus, both of which cause balance and gait issues. Dr. Elder, who does research on normal pressure hydrocephalus, plans to begin a study later this year to monitor the outcomes of patients with this condition and examine whether there is any association with spinal cord compression.

From Bob's perspective, the difference in his daily life before and after his diagnosis and surgery has been remarkable.

"This is a huge change from being in a wheelchair," Bob says. "I'm 90 percent better than I was. And though I still have some issues with balance, I can walk unaided."

Now that his diagnosis, treatment and rehabilitation are behind him, and he's regained the strength in his legs and much of his balance, Bob is looking forward to resuming his three weekly workouts at the YMCA with his wife.

"I'm quite grateful for the skill and knowledge of the doctors who treated me at Mayo," Bob says.

HELPFUL LINKS

• Learn more about hydrocephalus.
• Read about Mayo Clinic's Department of Neurosurgery.
• Explore Mayo Clinic's campus in Rochester.
• Request an appointment.

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Listen: POTS syndrome (Postural Orthostatic Tachycardia Syndrome)

The post Mayo Clinic Radio on Neurosciences: Postural Orthostatic Tachycardia Syndrome (POTS) appeared first on Mayo Clinic News Network.

ANSWER: A diagnosis of postural tachycardia syndrome, commonly known as POTS, typically is based on symptoms, along with the results of an assessment called a tilt table test. Although there’s no cure for postural tachycardia syndrome, often it can be managed effectively with lifestyle changes and medication. And fortunately, teenagers — the group most often affected by POTS — usually outgrow the disorder by the time they reach their 20s.

Postural tachycardia syndrome affects the autonomic nervous system, which controls involuntary body functions such as heart rate and blood pressure. In postural tachycardia syndrome, the nerves that regulate blood flow are out of balance, so enough blood doesn’t go to the right place at the right time. The result is a variety of symptoms, including an overly rapid heartbeat when shifting from lying down to standing up.

A person’s heart rate is usually about 70 to 80 beats per minute when resting. Normally, the heart rate increases by 10 to 15 beats per minute when standing up, and then it settles down again. For people with postural tachycardia syndrome, the heart rate goes up considerably higher when they stand, often increasing 30 to 50 beats per minute or more. This can lead to lightheadedness, dizziness and fainting.

Other postural tachycardia syndrome symptoms may include chronic fatigue; headaches or other types of chronic pain; and digestive problems, such as nausea and cramping. These symptoms may vary considerably from one person to another. If symptoms seem to be pointing to postural tachycardia syndrome, the diagnosis usually is confirmed using a tilt table test.

For a tilt table test, you begin by lying flat on a table. Straps are put around your body to hold you in place. After about 30 minutes of lying flat, the table is quickly tilted to raise your body to a head-up position — simulating a change in position from lying down to standing up. Then, your heart rate and blood pressure are monitored for about 10 minutes. In people who have postural tachycardia syndrome, the heart rate goes up by more than 30 beats per minute when tilted up (40 beats per minute or more for teenagers). Blood pressure remains steady or changes only slightly.

Postural tachycardia syndrome begins in the teenage or early adulthood years. Although postural tachycardia syndrome is a chronic condition, about 80 percent of patients grow out of it. Until that happens, treatment can ease postural tachycardia syndrome symptoms.

In people who have postural tachycardia syndrome, the blood vessels are too relaxed. Extra fluid is needed to fill up the vessels, allowing blood to flow properly. Drinking extra fluids alone isn’t enough. Increased salt intake is also necessary to hold fluid in the blood vessels. It’s also important for people with postural tachycardia syndrome to avoid caffeine and alcohol.

Exercise is critical. Engaging in daily, moderate, aerobic exercise — biking, rowing or swimming, for example — not only improves fitness and increases energy levels, but also works to retrain the autonomic nervous system to regulate blood flow correctly. Wearing garments that mildly compress the thighs and abdomen also can encourage proper blood flow and reduce postural tachycardia syndrome symptoms.

A variety of medications are available to treat postural tachycardia syndrome. But they are generally not effective if the strategies of fluid, salt, compression and exercise are not also in place.

Because postural tachycardia syndrome is a complicated disorder that can show up in a variety of ways, those with postural tachycardia syndrome may need to use several different treatment options. At times, it can be challenging to find a treatment regime that successfully controls all postural tachycardia syndrome symptoms. If you don’t respond well to initial treatment, it’s important to continue medical care and work with a provider familiar with postural tachycardia syndrome who can customize care to your individual needs. — Dr. Jeremy Cutsforth-Gregory, Neurology, Mayo Clinic, Rochester, Minnesota

The post Mayo Clinic Q and A: All about POTS — postural tachycardia syndrome appeared first on Mayo Clinic News Network.

Here's the Mayo Clinic Radio podcast.

The post Treatment options for kidney stones: Mayo Clinic Radio appeared first on Mayo Clinic News Network.

Kidney stones are small, hard mineral deposits that form inside your kidneys. If you've had them, you know that passing kidney stones can be painful. Depending on your situation, you may need nothing more than to take pain medication and drink lots of water to pass a kidney stone. In other instances, when the stones cause complications, more extensive treatment may be required. On the next Mayo Clinic Radio program, urologist Dr. David E. Patterson will cover treatment and prevention of kidney stones. Also on the program, colorectal surgeon Dr. Robert Cima will explain enhanced recovery after surgery — a technique that helps patients return home more quickly after an operation. And neurologist Dr. Jeremy Cutsforth-Gregory will discuss the difficult-to-diagnose disease of postural orthostatic tachychardia syndrome, commonly known as POTS.

The post Mayo Clinic Radio: Treatment options for kidney stones appeared first on Mayo Clinic News Network.

Listen to the program on Saturday, Jan. 14, at 9:05 a.m. CST.

Miss the show?  Here's the Mayo Clinic Radio podcast.

Follow #MayoClinicRadio, and tweet your questions.

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Mayo Clinic Radio produces a weekly one-hour radio program highlighting health and medical information from Mayo Clinic.

Access archived shows.

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It’s a condition with no outward symptoms. But for the hundreds of thousands of teens and adults in the U.S. living with postural orthostatic tachycardia syndrome, or POTS, the medical disorder has a significant impact on their lives. Christine Esposito is one of those people.

Christine was diagnosed with the condition in 2002 by Mayo Clinic neurologist Jeremy K. Cutsforth-Gregory, M.D.

POTS is a disorder that affects a person’s autonomic nerves — the nerves that control involuntary body functions, such as heart rate, blood pressure, body temperature, perspiration, and bowel and bladder functions. Not everyone has the same symptoms, but the condition universally causes rapid heart rates and dizziness when moving from a resting to standing position.

Christine’s symptoms began with fainting, heart palpitations and chest pains. Then they progressed to more serious problems, including migraines, chronic pain, gastrointestinal issues and chronic fatigue syndrome. Christine’s symptoms prevented her from going to school and, some days, from even getting out of bed.

“They teach you how to live with POTS, basically ─ everything from posture to exercise to eating.” — Christine Esposito

While there is no cure the condition, symptoms often can be managed with medications, along with behavior changes, such as exercising regularly; taking in salt, which allows the body’s vessels to retain fluid; and using leg compression, which boosts blood flow.

Thanks to education  and access to resources like Mayo Clinic’s POTS Boot Camp — a program that helps people learn to manage symptoms — Christine now understands how to better control her condition. “They teach you how to live with POTS, basically ─ everything from posture to exercise to eating,” Christine says.

For Christine, a furry canine friend who goes by the name of Zoe is also a comfort.

“On days that I don’t feel well, Zoe will lay by me. She will rest with me. She will walk to the bathroom with me,” Christine says. “On days I feel great, we are outside in the yard.”

Equipped with better understanding and tools to cope with her symptoms, Christine has been able to get back to enjoying her life once again.

To learn more about POTS and Christine’s story, watch the video below:

HELPFUL LINKS:

• Read more about POTS.
• Learn about the Department of Neurology at Mayo Clinic.
• Explore Mayo Clinic’s Rochester campus.
• Request an appointment.

The post Learning to Live Well With POTS Brightens Daily Life for Christine Esposito appeared first on Mayo Clinic News Network.

For people with postural orthostatic tachycardia syndrome (POTS), everyday tasks can be daunting. Symptoms such as fatigue, dizziness and stomach problems greatly impact quality of life. Patients with POTS may look healthy, but they say they feel terrible, making it hard for other people to understand. POTS falls under the category of disease called dysautonomia, and October is Dysautonomia Awareness Month.

In this Mayo Clinic Minute, reporter Vivien Williams talks to Dr. Jeremy Cutsforth-Gregory about POTS. He explains how one simple test can diagnose the condition and how treatment can improve symptoms.

Watch: The Mayo Clinic Minute

Journalists: Broadcast-quality video pkg (1:00) is in the downloads. Read the script.

Related posts:

Living with POTS, Oct. 24, 2016

The post Mayo Clinic Minute: What is POTS? appeared first on Mayo Clinic News Network.

Christine Esposito has suffered with POTS for many years. Her symptoms include dizziness, extreme fatigue, stomach problems and more. When a medical team at Mayo Clinic led by Dr. Jeremy Cutsforth-Gregory diagnosed her symptoms as POTS, the news came as a relief. She wasn't just too lazy to get out of bed and head to school. There was a real condition preventing her from doing so. For the Mayo Clinic News Network, reporter Vivien Williams shares Christine's story.

Watch: Living with POTS.

Journalists: Broadcast-quality video pkg (3:19) is in the downloads. Read the script. 

POTS and other malfunctions of the autonomic nervous system are grouped under the umbrella term, dysautonomia. October is Dysautonomia Awareness Month, and experts hope to educate people about these conditions.

For more information about POTS, visit the Dysautonomia International website.

The post Living with POTS appeared first on Mayo Clinic News Network.