{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T16:07:58Z","timestamp":1776096478609,"version":"3.50.1"},"reference-count":22,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","license":[{"start":{"date-parts":[[2026,1,12]],"date-time":"2026-01-12T00:00:00Z","timestamp":1768176000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,1,12]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>The association of idiopathic intracranial hypertension (IIH) with spontaneous skull base CSF leaks is well known; however, its role in spinal CSF leaks is poorly established. CSF-venous fistula (CVFs) are a recognized subtype of spinal CSF leaks, but they rarely recur after successful treatment. Brainstem sagging is a known consequence of spontaneous intracranial hypotension with variable clinical sequelae. Brainstem sagging has not previously been demonstrated to cause obstructive hydrocephalus.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>The authors describe the case of a female in her early 5th decade with presumed IIH-induced recurrent spinal CVFs. They detail the recurrent nature of her CVFs despite successful transvenous embolization, the advanced imaging techniques required for diagnosis, and the consequences of untreated intracranial hypotension, including bulbar dysfunction and obstructive hydrocephalus requiring external ventricular drainage. The placement of a ventriculoperitoneal shunt to prevent further spinal CVF recurrence is also described.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>This illustrative case highlights the complexity of treatment in recurrent spinal CVFs and intracranial hypotension. The authors detail the extreme consequences of untreated intracranial hypotension, including obstructive hydrocephalus and progressive bulbar dysfunction. In this context, the necessity of external ventricular drainage in order to equalize transtentorial pressure differentials and restore consciousness is demonstrated.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE25680\">https:\/\/thejns.org\/doi\/10.3171\/CASE25680<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case25680","type":"journal-article","created":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T12:00:00Z","timestamp":1769083200000},"source":"Crossref","is-referenced-by-count":0,"title":["Obstructive hydrocephalus secondary to brainstem sagging in recurrent cerebrospinal fluid\u2013venous fistulas: a diagnostic and therapeutic challenge. Illustrative case"],"prefix":"10.3171","volume":"11","author":[{"given":"Kyle","family":"Bennett","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hannah","family":"McDonald","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7682-3300","authenticated-orcid":true,"given":"Steven","family":"Bush","sequence":"additional","affiliation":[{"name":"Department of Interventional Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1187-039X","authenticated-orcid":true,"given":"James","family":"Dimou","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"7","key":"bib1","series-title":"Neurology","first-page":"673","article-title":"A classification system of spontaneous spinal CSF leaks","volume":"87","author":"Schievink","year":"2016","unstructured":"Schievink WIMaya MMJean-Pierre SNu\u00f1o MPrasad RSMoser FG.A classification system of spontaneous spinal CSF leaks. Neurology. 2016;87(7):673-679."},{"issue":"6","key":"bib2","series-title":"AJR Am J Roentgenol","first-page":"1418","article-title":"CSF-venous fistulas: anatomy and diagnostic imaging","volume":"217","author":"Kranz","year":"2021","unstructured":"Kranz PGGray LMalinzak MDHouk JLKim DKAmrhein TJ.CSF-venous fistulas: anatomy and diagnostic imaging. AJR Am J Roentgenol. 2021;217(6):1418-1429."},{"issue":"1","key":"bib3","series-title":"Curr Pain Headache Rep","first-page":"5","article-title":"CSF-venous fistula","volume":"25","author":"Roytman","year":"2021","unstructured":"Roytman MSalama GRobbins MSChazen JL.CSF-venous fistula. Curr Pain Headache Rep. 2021;25(1):5."},{"key":"bib4","series-title":"World Neurosurg","first-page":"91","article-title":"Surgical treatment efficacy of CSF-venous fistulas: systematic review","volume":"161","author":"Konovalov","year":"2022","unstructured":"Konovalov AGadzhiagaev VVinogradov ENikitin NEliava SKonovalov N.Surgical treatment efficacy of CSF-venous fistulas: systematic review. World Neurosurg. 2022;161:91-96."},{"issue":"11","key":"bib5","series-title":"AJNR Am J Neuroradiol","first-page":"1332","article-title":"Factors predictive of treatment success in CT-guided fibrin occlusion of CSF-venous fistulas: a multicenter retrospective cross-sectional study","volume":"44","author":"Callen","year":"2023","unstructured":"Callen ALCarlton Jones LTimpone VMFactors predictive of treatment success in CT-guided fibrin occlusion of CSF-venous fistulas: a multicenter retrospective cross-sectional study. AJNR Am J Neuroradiol. 2023;44(11):1332-1338."},{"issue":"12","key":"bib6","series-title":"J Neurointerv Surg","first-page":"1256","article-title":"Clinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization","volume":"16","author":"Brinjikji","year":"2024","unstructured":"Brinjikji WMadhavan AGarza IClinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization. J Neurointerv Surg. 2024;16(12):1256-1263."},{"issue":"1","key":"bib7","series-title":"Neurol Neurochir Pol","first-page":"54","article-title":"Recurrence of cerebrospinal fluid-venous fistulas at different spinal levels following transvenous embolisation or blood\/fibrin glue patching","volume":"58","author":"Zayat","year":"2024","unstructured":"Zayat RFermo OPHuynh TJ.Recurrence of cerebrospinal fluid-venous fistulas at different spinal levels following transvenous embolisation or blood\/fibrin glue patching. Neurol Neurochir Pol. 2024;58(1):54-59."},{"issue":"1","key":"bib8","series-title":"Am J Rhinol Allergy","first-page":"36","article-title":"Spontaneous skull base cerebrospinal fluid leaks and their relationship to idiopathic intracranial hypertension","volume":"35","author":"Bidot","year":"2021","unstructured":"Bidot SLevy JMSaindane AMSpontaneous skull base cerebrospinal fluid leaks and their relationship to idiopathic intracranial hypertension. Am J Rhinol Allergy. 2021;35(1):36-43."},{"issue":"11","key":"bib9","series-title":"Mayo Clin Proc","first-page":"1241","article-title":"Intracranial hypertension after treatment of spontaneous cerebrospinal fluid leaks","volume":"77","author":"Mokri","year":"2002","unstructured":"Mokri B.Intracranial hypertension after treatment of spontaneous cerebrospinal fluid leaks. Mayo Clin Proc. 2002;77(11):1241-1246."},{"issue":"4","key":"bib10","series-title":"J Neuroophthalmol","first-page":"487","article-title":"Do most patients with a spontaneous cerebrospinal fluid leak have idiopathic intracranial hypertension?","volume":"39","author":"Bidot","year":"2019","unstructured":"Bidot SLevy JMSaindane AMOyesiku NMNewman NJBiousse V.Do most patients with a spontaneous cerebrospinal fluid leak have idiopathic intracranial hypertension? J Neuroophthalmol. 2019;39(4):487-495."},{"issue":"19","key":"bib11","series-title":"Neurology","first-page":"e1638","article-title":"Coma: a serious complication of spontaneous intracranial hypotension","volume":"90","author":"Schievink","year":"2018","unstructured":"Schievink WIMaya MMMoser FGJean-Pierre SNu\u00f1o M.Coma: a serious complication of spontaneous intracranial hypotension. Neurology. 2018;90(19):e1638-e1645."},{"issue":"7","key":"bib1","series-title":"Neurology","first-page":"673","article-title":"A classification system of spontaneous spinal CSF leaks","volume":"87","author":"Schievink","year":"2016","unstructured":"Schievink WIMaya MMJean-Pierre SNu\u00f1o MPrasad RSMoser FG.A classification system of spontaneous spinal CSF leaks. 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AJNR Am J Neuroradiol. 2023;44(11):1332-1338."},{"issue":"12","key":"bib6","series-title":"J Neurointerv Surg","first-page":"1256","article-title":"Clinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization","volume":"16","author":"Brinjikji","year":"2024","unstructured":"Brinjikji WMadhavan AGarza IClinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization. J Neurointerv Surg. 2024;16(12):1256-1263."},{"issue":"1","key":"bib7","series-title":"Neurol Neurochir Pol","first-page":"54","article-title":"Recurrence of cerebrospinal fluid-venous fistulas at different spinal levels following transvenous embolisation or blood\/fibrin glue patching","volume":"58","author":"Zayat","year":"2024","unstructured":"Zayat RFermo OPHuynh TJ.Recurrence of cerebrospinal fluid-venous fistulas at different spinal levels following transvenous embolisation or blood\/fibrin glue patching. Neurol Neurochir Pol. 2024;58(1):54-59."},{"issue":"1","key":"bib8","series-title":"Am J Rhinol Allergy","first-page":"36","article-title":"Spontaneous skull base cerebrospinal fluid leaks and their relationship to idiopathic intracranial hypertension","volume":"35","author":"Bidot","year":"2021","unstructured":"Bidot SLevy JMSaindane AMSpontaneous skull base cerebrospinal fluid leaks and their relationship to idiopathic intracranial hypertension. Am J Rhinol Allergy. 2021;35(1):36-43."},{"issue":"11","key":"bib9","series-title":"Mayo Clin Proc","first-page":"1241","article-title":"Intracranial hypertension after treatment of spontaneous cerebrospinal fluid leaks","volume":"77","author":"Mokri","year":"2002","unstructured":"Mokri B.Intracranial hypertension after treatment of spontaneous cerebrospinal fluid leaks. Mayo Clin Proc. 2002;77(11):1241-1246."},{"issue":"4","key":"bib10","series-title":"J Neuroophthalmol","first-page":"487","article-title":"Do most patients with a spontaneous cerebrospinal fluid leak have idiopathic intracranial hypertension?","volume":"39","author":"Bidot","year":"2019","unstructured":"Bidot SLevy JMSaindane AMOyesiku NMNewman NJBiousse V.Do most patients with a spontaneous cerebrospinal fluid leak have idiopathic intracranial hypertension? J Neuroophthalmol. 2019;39(4):487-495."},{"issue":"19","key":"bib11","series-title":"Neurology","first-page":"e1638","article-title":"Coma: a serious complication of spontaneous intracranial hypotension","volume":"90","author":"Schievink","year":"2018","unstructured":"Schievink WIMaya MMMoser FGJean-Pierre SNu\u00f1o M.Coma: a serious complication of spontaneous intracranial hypotension. 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