Talk:Spontaneous cerebrospinal fluid leak

Refs

Might anyone be able to give me a hand properly formatting the references? Sorry I dump just the URL. Thanks. Bstone (talk) 22:09, 4 December 2008 (UTC)

reflist

Dear folks, I think I may have killed the reflist in my attempt to add references. It just isn't showing up any more. Is it possible to get some help? Basket of Puppies 18:11, 13 January 2009 (UTC)

Move and name change

the title of this wikipedia entry is a misnomer; "spontaneous" is a characteristic of csf leak, concerning the pathology of the origin of some csf leaks. there are traumatic csf leaks (lumbar puncture being the most commonly understood), for which if this wikipedia entry is to remain entitled as "spontaneous", it begs the creation of a "traumatic cerebrospinal fluid leak". i think most knowledgeable, or even more so, chronic leakers would agree that one entry is sufficient, "Cerebrospinal fluid leak", which would encompass all kinds, types and locations of a csf leak. (one may benefit from a juxtaposition to hemophilia in various regards.)

the misuse of the word "spontaneous" in this health condition misleads as to the meaning of the word 'spontaneous', and does lead to an improper diagnosis as well as possible and definitive mistreatment thus doing harm to a candidate for diagnosis and actual leaker (diagnosed or not). numerous leakers have been made so by lumbar puncture. as it has been the practice of many inexperienced, ignorant and/or obstinate physicians to rule out "spontaneous" cerebrospinal fluid leak post lumbar puncture by using the "gold standard" (wouter schievink, cedars sinai) which is to introduce contrast agent to the csf via a lumbar puncture, the physician not only compounds the problem, the misled physician creates what the physician is looking for, a (lumbar puncture) leak. the fact that ailments and symptoms indicative of a csf leak begin so proximate to a lumbar puncture is often no deterrent to neurosurgeons ordering another lumbar puncture to look for a "spontaneous"; for indeed, the "spontaneous" has often been more the target of discovery than it has been to rule out csf leak.

medical journals and publishing researchers entitling csf leak papers with the word "spontaneous" and doctors calling csf leaks "spontaneous" are vastly insufficient and completely unscientific reasons to entitle the condition in itself as so. "spontaneous" in a csf leak candidate is just as much part of the diagnosis as is "csf leak". i recall physicians of the past bloodletting patients until all the bad humors were removed.

dropping the unnecessary and harmful misuse of the word "spontaneous" from 'cerebrospinal fluid leak' will more accurately describe the condition and lead to less medical injury. i write this from both the personal experience of being a chronic leaker, for which a connective tissue disorder contributed but did not cause the condition, whose condition mislabeled as "spontaneous" led to further injury by physicians and having helped numerous other traumatic leakers whose injuries were just so compounded by physicians. furthermore, the NIH Office of Rare Diseases Research recognizes the condition as "Cerebrospinal fluid leak" NIH ORDR, not "Spontaneous cerebrospinal fluid leak" for which the Office of Rare Diseases Research has no entry. --Mr etler (talk) 17:46, 8 June 2012 (UTC)

There is an article entitled cerebrospinal fluid leak which deals with the non-spontaneous type of leak (ie LP gone bad, trauma, etc). This article deals with the medical problem of a CSF leak of non-trama origins, thus the spontaneous name. All the medical articles about this type of CSF leak call it a spontaneous leak. Thank you for your comments. Basket of Puppies 18:54, 8 June 2012 (UTC)

in the wikipedia article "Spontaneous cerebrospinal fluid leak" it is written, "CSF leak". i take liberty in assuming that "CSF" is initialism (as opposed to acronym) for 'cerebrospinal fluid". and "CSF" together with the word "leak" but without initialism is properly written and understood as "cerebrospinal fluid leak". furthermore the term "CSF leak" is often a repeated entry in the article which at the date of this comment is in deed repeated no less than 56 times. do you mean to tell me that each of these entries should be understood as 'traumatic' cerebrospinal fluid leak? for you do suggest that 'cerebrospinal fluid leak' by definition means only the traumatic in origin leaks.

and then there are the entries, "spontaneous cerebrospinal fluid leak" and even the title of the article "Spontaneous cerebrospinal fluid leak". should these be understood to mean "spontaneous traumatic cerebrospinal fluid leak"? or should they be understood to mean that "traumatic" is to be dropped from the understanding of the term "cerebrospinal fluid leak" only when the phrase is prefixed by the word "spontaneous"?

and which part of the term "CSF leak" is 'traumatic' assigned to? the "CSF" part or the "leak" part.

the confusion and difficulty in syntax is unnecessary.

go to any neurosurgeon, may i suggest, say the words "cerebrospinal fluid leak" and ask the neurosurgeon to interpret the categorization of your phrase as to mean "traumatic", "spontaneous" or both.

you suggest that the entry 'cerebrospinal fluid leak' should not discuss 'spontaneous' csf leaks, that it should be restricted to csf leaks strictly of traumatic origin. extending the logic, should it be properly entitled 'traumatic cerebrospinal fluid leaks'? or should it be presumed and understood that 'cerebrospinal fluid leak' only means traumatic in leak origin, causation? that cerebrospinal fluid leaks, therefore are not and never are spontaneous in causation pathology? what other arbitrary understandings should cerebrospinal fluid leaks, excuse me, spontaneous cerebrospinal fluid leaks (what confusion!) be assigned.

do you suggest there is no categorization (wikipedia entry) possible for cerebrospinal fluid leak which encapsulates all origin, causation and pathology of the medical problem? if not, would you think about creating that categorization now?

i suggest there is already. it is, 'cerebrospinal fluid leak', the meaning of which encapsulates all non-deliberate or unwanted extra-dural or extra-pia matter or extra-choroid plexus (should we come to that understanding for the latter) occurrences of cerebrospinal fluid. the pathology in causation or origin is irrelevant to the syntax of the proper title for the phrase which should properly encapsulate the condition.

following your reasoning, then, do you suggest that there be multiple wikipedia entries regarding csf leaks?

-cerebrospinal fluid leaks

-spontaneous cerebrospinal fluid leaks

-spinal cerebrospinal fluid leaks

-cranial cerebrospinal fluid leaks

-traumatic cerebrospinal fluid leaks

-traumatic, spinal cerebrospinal fluid leaks

-spontaneous, spinal cerebrospinal fluid leaks

-traumatic, cranial cerebrospinal fluid leaks

-spontaneous, cranial cerebrospinal fluid leaks

-cervical spinal cerebrospinal fluid leaks

-cervical-thoracic junction spinal cerebrospinal fluid leaks

-thoracic spinal cerebrospinal fluid leaks

-lumbar spinal cerebrospinal fluid leaks

-nasal cranial cerebrospinal fluid leaks

-otic cranial cerebrospinal fluid leaks

-ocular cranial cerebrospinal fluid leaks

-chronic cerebrospinal fluid leaks

-chronic, spontaneous cerebrospinal fluid leaks

-chronic, traumatic cerebrospinal fluid leaks

-occult cerebrospinal fluid leaks

-occult, spontaneous cerebrospinal fluid leaks

-occult, traumatic cerebrospinal fluid leaks

-chronic, occult cerebrospinal fluid leaks

-chronic, occult spontaneous cerebrospinal fluid leaks

-chronic, occult traumatic cerebrospinal fluid leaks

we could apply all the combinations of traumatic, spontaneous, chronic and occult to the various classifications, the particular anatomical locations, etc, and create a wikipedia entry for each. ig: chronic, occult, spontaneous, nasal cranial, cerebrospinal fluid leaks. but there should be an entry for chronic, occult, nasal cranial, cerebrospinal fluid leaks of traumatic origin as well.

why stop with one part of the pathology? just because it has been published so?

if you would not support a wikipedia entry for each sub-classification of csf leak, please help me understand, explain why not.

why do you think a contributory factor in causation in pathology is sufficient to maintain a separate entry?

how does 'spontaneity' in the pathology and only the pathology of the origin of the disease let alone the rest of the pathology of the disease justify maintaing this entry title?

again, there is no reason, other than specious, to maintain the misnomer of the article title "spontaneous" just because "All the medical articles about this type of CSF leak call it a 'spontaneous' leak". please explain the reason of justification instead of just repeating as a child who sticks his fingers in his ears saying, 'nah nah, i can't hear you'. most of the articles to which you refer, within the text of their dialogue, do not address the reasons why or how of the particulars in the pathology of csf leak origin to justify labeling the articles 'spontaneous'. the articles are titled so because of (poor) tradition, which is the basis of your reasoning to continue to entitle the wikipedia article so. you argue to continue blood letting because our medical forefathers did it?

the current use of the word 'spontaneous' as it is applied to the vast majority of cerebrospinal fluid leaks is akin to calling episodes of acute myocardial infarction 'spontaneous heart attacks'. in deed, "myocardial infarction results from atherosclerosis" and "intense exertion, be it psychological stress or physical exertion, especially if the exertion is more intense than the individual usually performs" (wikipedia). so should we call 'myocardial infarction' 'spontaneous heart attack'? and does this explanation of cardiac arrest sound familiar? well, it should if you understand csf leak pathology and are remotely read of wouter schivienk's school of thought ("underlying genetic weakness and a more or less trivial traumatic event" - i quote from weak memory). wouter has also said that we (medical establishment) are about 10% out of the dark ages for treating csf leaks (2006, Maxine Dunitz Neurological Institute, Cedars-Sinai Hospital). and wouter schivienk is also responsible for practicing the effects of the equivalent of blood letting on csf leak candidates and patients for reasons i have already discussed (and you have chosen not to address in your response to my comments). he also maintains an archaic and willingly ignorant definition of which csf leaks are "traumatic" and which are "spontaneous".

the use of the word "spontaneous" in most literature regarding csf leaks is nothing more than immaturity in the field. just as in the past, before the discovery of the role of atherosclerosis, all heart attacks were thought to be spontaneous. if i were to guess the etymology of the word 'spontaneous' as it is commonly ascribed in csf leaks (and entitled papers published), it is probably in the tradition of the practice of calling the water which circulates in the cerebrospinal cavity, 'cerebrospinal fluid'. the medical establishment has come up with nothing better. it is akin to calling the liquid in the (blood) circulatory system 'arteryvein fluid' or "lungsheartliverkidniesmusclesboneskinbonemarrowstomachspleen fluid". 'water' is a more accurate word, as 99% of csf is water. gasoline and mercury at room temperature are both fluids. wikipedia defines 'fluid': "Fluids are a subset of the phases of matter and include liquids, gases, plasmas and, to some extent, plastic solids". the use of the word 'fluid' in the term 'cerebrospinal fluid' is archaic too.

ignorance is often demonstrated in etymology. but maintaining that ignorance in light of better understanding is stubbornness.

spontaneity in csf leaks is a sub-categorization. insisting it as a title of wikipedia entry is a disservice to the advancement of knowledge in the treatment of csf leaks. the word's misuse has lead to the mistreatment of csf leak patients and the worsening of their condition. insisting on maintaining it in light of understanding is akin to the preference of the church over science in the matters of science in the dark ages.

furthermore, the article "spontaneous cerebrospinal fluid leak" with as much common information properly attributed to 'cerebrospinal fluid leaks" demands no less entry of such information in the latter article and significant duplication of information. this would decrease the efficiency, authority, and reputation of Wikipedia.

--Mr etler (talk) 00:28, 15 June 2012 (UTC)

I don't know how else to answer the question. The condition breaks down between traumatic and spontaneous leaks. This article deals with spontaneous leaks, both in the spine and the cranial vault. The other article deals with traumatic leaks. I invite you to review Wikipedia's guidelines and policies and then proceed with editing. Thank you. Basket of Puppies 07:05, 15 June 2012 (UTC)

I see that the article has been moved and the name has changed, dropping "spontaneous". In every paper that has been written about it the word "spontaneous" is always included, usually as the first word in the name of the condition. As someone who suffers from this every single doctor, including the world experts, refer to this as 'spontaneous cerebrospinal fluid leak'. The Mayo Clinic, Ceders Sinai in LA and Duke Univ Med Center- all places where this is treated- refer to it as 'spontaneous cerebrospinal fluid leak', as it happens spontaneously...most likely due to a connective tissue disorder. But I digress. Before I undo the edits moving and changing the name I would like to hear from the editor who did this to understand why and see if I am missing something. Thank you. Basket of Puppies 15:55, 2 February 2009 (UTC)

Per Wikipedia:Manual_of_Style_(medicine-related_articles)#Naming_conventions, we use ICD-10 in most circumstances, unless there is an overwhelming consensus in the literature to use a different term. Try clicking on the following link (you'll have to copy and paste it into your browser, since it has brackets in it):

• http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term=(Cerebrospinal[Title]+AND+fluid[Title]+AND+leak[Title])+AND+%22loattrfree+full+text%22[sb]

You will see that there are 21 free journal articles with "cerebrospinal fluid leak" in the title, and not one of the 21 includes the word "spontaneous". If you search non-free articles, you get similar results. Using Google book search, "cerebrospinal+fluid+leak" yields 767 results, and "spontaneous+cerebrospinal+fluid+leak" yields 30, with only 8 of those coming since 2000. So ICD-10 wouldn't be overriden in this case.

As written, the article described cerebrospinal fluid leaks in general. It certainly could be expanded to explain when the word "spontaneous" is used, and why. If you would like assistance in that expansion, I would be happy to offer my services. I'd also like to let you know about User:Diberri/Template filler. This tool is very useful for providing the reference formatting needed for MEDMOS compliance. --Arcadian (talk) 18:43, 2 February 2009 (UTC)

Arcadian, every paper written about this condition includes the word "spontaneous". Simply look at the refs for this- they all write about a spontaneous fluid leak, such as:

• Surgical Treatment of Spontaneous Spinal Cerebrospinal Fluid Leaks
• Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension
• Spontaneous CSF leaks: Underlying disorder of connective tissue
• Headache and spontaneous low cerebrospinal fluid pressure syndrome Neurol Sci (2007) 28:S232–S234

DOI 10.1007/s10072-007-0785-1

• Spontaneous spinal cerebrospinal fluid leaks

So, as you can see, every paper is about a spontaneous leak, not CSF leak in general. CSF leak can easily be its own article and have a link to this one, but they are infact distinct. I will go ahead and change the title. Basket of Puppies 21:04, 2 February 2009 (UTC)

Spinal meninges image and info box- how to put them together?

{{help}} I am trying to figure out how to put the spinal meninges image and info box together. I don't seem to be having much luck. Might someone give me a hand? Thanks! Basket of Puppies 00:34, 15 May 2009 (UTC)

Done. Cheers.--Fuhghettaboutit (talk) 00:43, 15 May 2009 (UTC)

Cheers! Basket of Puppies 00:44, 15 May 2009 (UTC)

Scope still limited

How common is this condition?

What is its history and when was it first recognized?--Doc James (talk · contribs · email) 22:36, 15 May 2009 (UTC)

The condition is more common than thought, but underdiagnosed.

See Neurol Sci (2007) 28:S232–S234 "We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with headache associated with spontaneous intracranial hypotension syndrome (SIH)."

and

"The syndrome of low-pressure CSF headaches was first recognized following diagnostic lumbar puncture. As early as the 1930s, Schaltenbrand in Germany and Wolt- man in the United States were familiar with “spontane- ous” posture-related low-pressure headaches that did not develop after lumbar puncture.23,31bar puncture. In most patients low or unmeasurable CSF pressures are observed; however, in a significant minority normal opening pressures will be demonstrated on serial lumbar punctures.9,12Increased levels of CSF protein con- centration and a lymphocytic pleocytosis are common.12 " Neurosurg Focus 9 (1):Article 7, 2000,

and

The spontaneous form of intracranial hypotension was first described in 1938,2 and much has been learned about this syndrome, particularly since the early 1990s,3-15 but an initial misdiagnosis remains the norm. Unfamiliarity with spontaneous intracranial hypotension among physicians in general and the unusually varied spectrum of clinical and radiographic manifestations may all contribute to a delay in diagnosis that often is measured in months or even years and decades.1

JAMA. 2006;295:2286-2296.

Basket of Puppies 23:09, 15 May 2009 (UTC)

Reference

Refs on one line are easier for others to view. --Doc James (talk · contribs · email) 02:34, 16 May 2009 (UTC)

Hi, Doc James! How are you? I'm afraid I don't think I understand what you mean. Can you explain it to me? Thanks! Basket of Puppies 00:51, 17 May 2009 (UTC)

Rather than having the ref written over many lines you can put it all on one line. Makes it easier for others to edit.--Doc James (talk · contribs · email) 01:18, 11 June 2009 (UTC)

Oh that's really good to know! How can I be able to do this? I don't think I know the code. Thanks, Jmh! Basket of Puppies 02:25, 11 June 2009 (UTC)

Intro/lede section

Hi, friends! I saw that there was some concern that the intro may not have fully summarized the article, so I went ahead and added two more lines. I think that it does give a full summary, but I think it's good to chat about it before we remove the tag. What do you all say? Basket of Puppies 00:57, 17 May 2009 (UTC)

History

As published by Bahram Mokri, M.D. Department of Neurology, Mayo Clinic, Rochester, Minnesota here

George Schalten-brand, a German neurologist, in a German-language arti-cle in 193845 and in an English-language article in 1953 emphasized the term “aliquorrhea,” a condition marked by very low, unobtainable, or even negative CSF pressures that were clinically manifested by orthostatic headaches and other features that later came to be recognized as spontaneous intracranial hypotension. A few decades ear-lier the same syndrome had been described in the French literature as “hypotension of spinal fluid” or “ventricular collapse.”46Initially it was theorized that the cause of ali-quorrhea or spontaneous intracranial hypotension wasdecreased CSF production or increased CSF absorption. However, modern evidence has not provided support for either theory, but it has implicated CSF leakage. Under-standably the technology of the time could not have al-lowed Schaltenbrand or his contemporaries to assess pa-tients adequately for CSF leakage.11 In the United States, as early as 1940, Henry Woltman58 of the Mayo Clinic wrote about “headaches associatedwith decreased intracranial pressure” and gave a concise description of the syndrome, stating that “occasionally an occipital or frontal headache comes on only when the patient is up and about and leaves when the patient lies down. Such a headache is often associated with low pres- sure of the spinal fluid. Thus, it resembles post-puncture headache.” It is clear, therefore, that in this country the en-tity was quite known to some clinicians in 1930s if not earlier. The full clinical manifestations of intracranial hypoten-sion or CSF leak were described in several publications reported between the 1960s and early 1990s. The introduction of radioisotope cisternography,12,22,33,34,57 water-soluble myelography, and CT myelography provided the clinicians with more effective tools to diagnose and locate CSF leaks. In the 1990s we learned of the discov-ery of MR imaging–documented abnormalities in CSF volume depletion due to CSF leakage or CSF shunt over-drainage.12,19,30,36,44 All of these discoveries have resulted in broader recognition of the syndrome and its variations.

This seems to be as good as a history as one can hope for. I will try to paraphrase it, with using some other sources, and insert it into the article. Basket of Puppies 07:34, 17 May 2009 (UTC)

I have summarized the above and I am curious what the opinion is about the history section. Thanks!!!! Basket of Puppies 00:55, 20 May 2009 (UTC)

Epidemiology

As written by Wouter I. Schievink, MD "Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension" in JAMA Vol. 295 No. 19, May 17, 2006:

Once considered an exceedingly rare disorder, recent evidence suggests that spontaneous intracranial hypotension is not that rare and has to be considered an important cause of new daily persistent headaches, particularly among young and middle-aged individuals. In the past, our knowledge regarding spontaneous

intracranial hypotension was derived from case reports only, and no epidemiologic data were available. In a community-based study conducted in 1994, the prevalence of spontaneous intracranial hypotension was estimated at 1 per 50 000.16 In a more recent emergency department–based study (2003-2004),17 spontaneous intracranial hypotension was half as common as spontaneous subarachnoid hemorrhage, for an estimated annual incidence of 5 per 100 000. Comprehensive population-based epidemiologic studies, however, are not yet available. In the past, spontaneous intracranial hypotension was probably more frequently underdiagnosed than it is now, and it is unlikely that there has been an actual increase in its incidence, although that possibility cannot be entirely excluded. Spontaneous intracranial hypotension affects women more frequentlythan men, with a female-male ratio of approximately 2:1.1-16 Onset of symptoms typically is in the fourth or fifth decade of life, with a peak

incidence around age 40 years, but children and elderly persons also may be affected.1-16

I will go ahead and try to summarize this and insert it in the appropriate section. Basket of Puppies 05:43, 20 May 2009 (UTC)

I am changing the ratio by multiplying by 10. I do not think that a ratio of 2:1.1 is appropriate when dealing with numbers of people. Although I do not believe that no ratios should have fractions, I strongly disagree with having a ratio dealing with items that can not be split without changing what it is (people, animals, atoms, et cetera) including fractions. If you disagree with this, please talk to me on my talk page. I am not trying to insult anyone, but I feel that under no circumstances should people be split, even in ratios. I am also not trying to remove the information from its original source, but trying to keep people from being chopped up (figuratively speaking). Again, please bring up any disputes with this edit on my talk page. Thanks, and Happy Editing! Poker5463 ^Repeater 00:47, 24 June 2009 (UTC)

Is it up to Wikipedia to suggest new names and acronyms? And what about cranial leaks?

Basket of Puppies: nice start!

1) I don't think "Spontaneous cerebrospinal fluid leak (SCFL) " is commonly used in the literature. It should be "Spontaneous intracranial hypotension (SIH)".

2) It should be made clear from the outset that the other kind of fluid leak that arises from meninges in the cranium (often due to elevated ICP) are (confusingly?) not encompassed by the scope of present article. —Preceding unsigned comment added by 98.221.1.62 (talk) 17:58, 20 May 2009 (UTC)

Hi, 98.221.1.62! I am really glad you've chimed in here. To respond, 1) You might be right! Perhaps we sould remove the acronym of SCSFL and only use SIH. 2) Do you think you can elaborate? No doubt there are indeed other fluid leaks, which is thy the cerebrospinal fluid leak article exists. The scope of this one is specific to spontaneous leaks. What do you think? I'd love to collaborate with you on the regular fluid leak article. Basket of Puppies 18:07, 20 May 2009 (UTC)

---

Sure, BoP, re 2) it's not clear why 'spontaneous' leaks occur only in the lower part of the cranio-spinal sac, right? Spontaneous, or at least traumatic, rhinogenic leaks do occur e.g. in connection with diving (cribiform plate or ethmoid/sphenoid fractures I think + dural tear). This of course relates to 1). Just emphasizing to start with that the scope is restricted to spinal leaks would do. —Preceding unsigned comment added by 98.221.1.62 (talk) 18:32, 20 May 2009 (UTC)

PS: I'll need to reincarnate -- busy now but will create account and long on in a day or two. —Preceding unsigned comment added by 98.221.1.62 (talk) 18:36, 20 May 2009 (UTC)

Pathophysiology section

There was a concern put forth in the GA1 review that there was no "pathophysiology" section. Since this is generally the same as causes, I have retitled this section to be "Causes and Pathophysiology". What do people think? Basket of Puppies 22:45, 20 July 2009 (UTC)

GA Review 2

This review is transcluded from Talk:Spontaneous cerebrospinal fluid leak/GA2. The edit link for this section can be used to add comments to the review.

1. Well-written N

   (a) the prose is clear, concise, and understandable to an appropriately broad audience; spelling and grammar are correct N

   • Lengthy technical terms are repeated unnecessarily, even when an abbreviation for them has been introduced. As a result, the prose is difficult to read and does not "flow". Done
   • Some verbs are apparently missing. (e.g. "A 2003-2004 Emergency Room-based study indicated that spontaneous CSF leak resulting in spontaneous intracranial hypotension at 5 per 100,000")  Done
   • Some sentences are too lengthy and should be restructured. (e.g. "As a result of this descension of the brain is believed to stretch or impact various nerve complexes, including the eighth cranial nerve, causing hearing problems or vertigo, the optic nerve (the 2nd cranial nerve, which transmits visual information to the brain) or Optic chiasm (where the optic nerves partially cross), causing visual blurring, the facial nerve (the ninth (IX) cranial nerve), causing facial numbness and weakness and chorda tympani, or the glossopharyngeal nerve, causing taste distortion.")  Done
   • Using its opening two sentences, the Epidemiology section carefully introduces the terms "incidence" and "prevalence" with no apparent connection to anything else in the article.  Done

   (b) it complies with the Manual of Style guidelines for lead sections, layout, words to watch, fiction, and list incorporation N

   • A lead section should summarize the content of the article. In this article, the lead section does not do that, but instead introduces many technical terms and definitions. Done
   • The lead section carefully explains dura mater, but not meninges. The opening paragraph is not friendly to read, even for someone trained in biology.  Not done Are you certain? I had this reviewed by friends who tell me just the opposite. Basket of Puppies 02:28, 19 August 2009 (UTC)
   • Some highly technical jargon is neither explained nor linked (e.g. " Reversible Frototemporal Dementia") Done
   • Each paragraph has its own subsection, even when the paragraph is only one or two sentences. These short, choppy section should either be expanded into full sections, or else combined with other sections. Not done

2. Factually accurate and verifiable

   (a) it contains a list of all references (sources of information), presented in accordance with the layout style guideline N

   • Minimal reference content is not given. A reference should include the author(s) and date for each source, and should not summarize the content of that source. Summary of information should appear either in the article itself, or may be placed in a separate Notes section, but should not appear as part of the source attribution. Not done I have to disagree with this. Every science journal uses the references section in order to explain and add content that wouldn't be appropriate or fit into the main body of the article. Basket of Puppies 02:44, 19 August 2009 (UTC)

   (b) reliable sources are cited inline. All content that could reasonably be challenged, except for plot summaries and that which summarizes cited content elsewhere in the article, must be cited no later than the end of the paragraph (or line if the content is not in prose) Y

   (c) it contains no original research Y

3. Broad

   (a) it addresses the main aspects of the topic - This cannot be determined at this time because of the overly technical jargon and difficult prose.

   (b) it stays focused on the topic without going into unnecessary detail (see summary style) Y

4. Neutral Y
5. Stable Y
6. Illustrated

   (a) media are relevant to the topic, and have suitable captions Y - All images uploaded to Commons.

   (b) media are relevant to the topic, and have suitable captions N - Several captions are uninformative. Done

Additional specific notes:

• It is poor style to use images in varying sizes near each other, although that is not a technical requirement for GA status.

Overall assessment: Fail. --EncycloPetey (talk) 00:35, 17 August 2009 (UTC)

CommentI will immediately begin to fix the issues raised above. I am curious, however, if the issues warranted a quickfail? Perhaps they could be corrected as part of the GA review? Basket of Puppies 01:35, 17 August 2009 (UTC)

This wasn't a quickfail, which is where certain basic criteria haven't been met, and so the article need not be read in detail. I read the article quite thoroughly and spent hours drafting the review. If this were the first time this article had gone through GA, I might have considered holding it for a week for improvement, but this is the second pass through GAN (nominated again barely a month after the first fail) and the required changes are rather substantial. This article needs much work to make the prose understandable to an expert reader, and that's not something that can be corrected quickly. Add to that the other several issues across multiple GA criteria. You are always welcome to nominate again when the article has been improved. You might seek help at the Wikipedia:WikiProject Medicine in improving the article's prose and readability before resubmitting.

Please note that in the review above, some examples were used to represent larger problems. In responding to the review, you have only tried to address the specific examples given, and not the larger problems. For example, while you have adjusted the technical jargon "Reversible Frototemporal Dementia" and checked that item as "done"; it isn't actually done because there is a lot of other technical jargon with the same problem (e.g. "opening fluid pressure", "autonomic dysfunction", and "radioactive contrast"). Again, these are examples of the larger problem and not the only such words to be corrected. Instead of focussing on improving the few specific examples that are pointed out, you need to look beyond those specifics to the larger problem that is indicated, and correct that problem throughout the article.

Likewise, you have checked the first point as "done", but it isn't. Look again at the opening two paragraphs and see just how many times "cerebrospinal fluid leak" is repeated, sometimes more than once in a sentence. Pronouns (and abbreviations) are our friends.

Again, on the issue of missing verbs: You checked this as "done", but the example's subordinate clause still has no verb. I'm not sure what the sentence is supposed to say, but it's still not a complete sentence because it's missing the verb in what I assume is meant to be a subordinate clause.

For the issue of references: Wikipedia is not a technical journal. We have our own style guide, just as each publication has a style guide of its own. The WP style is to include authors and dates, and not to include a summary of the article as part of the citation. This is also true of 99% of the scientific journals I have used. You are free to disagree, but the requirements for GA specify that certain aspects of Wikipedia's manual of style must be met. If you choose not to meet them, then the article cannot be accepted as for GA status.

For image captions, you have added additional text, but the text does not tie the contents of the picture to the article. The last image, for example, needs a caption that says what it is the picture shows, and interprets what the viewer is seeing. Right now, it contains what appears to be a random statement. All this is going to take a lot of work, and (as I said) you should try seeking help from the medical WikiProject on this. --EncycloPetey (talk) 03:57, 19 August 2009 (UTC)

Response I believe I understand what you are saying. I have begun to request additional editorial assistance from the Medicine project and from the GA collaboration team. Hopefully with a few more hands on this the issues you raise can be remedied. Basket of Puppies 04:49, 19 August 2009 (UTC)

Scope

The scope is still limited.

Classification into spinal verse is rhino / oto is not addressed. Here are some refs: http://scholar.google.ca/scholar?q=Spontaneous+cerebrospinal+fluid+leak&hl=en&btnG=Search http://www.springerlink.com/content/60518137074710mu/fulltext.pdf?page=1 This paper looks good. It says only 4% of CSF leaks are spontaneous. Doc James (talk · contribs · email) 05:23, 19 August 2009 (UTC)

Agreed! This paper discusses rhino leak, tho it is somewhat older. I will insert oto and rhino leaks into the article utilizing the gscholar sources. Basket of Puppies 13:44, 19 August 2009 (UTC)

Diberris tool for citations

Diberri's tool is the most common tool to format citations to scientific journals in wikipedia. It would probably be a good idea if you changed the citation style of the references you have, now that you do not have many references, using the tool. You simply have to search for an article in pubmed, copy its number id and paste it into the tool and will give you the formatted citation. Afterwards you only have to add it to the article. Bests.--Garrondo (talk) 13:00, 20 August 2009 (UTC)

Hi, Garrondo! Thank you so much for the tip! I went ahead to the link but I got the following

Internal Server Error (500)

The server encountered an internal error and is unable to complete your request at this time. If the problem persists, please contact the owner of the tool you are trying to use and inform them of this error, quoting the following information:

• Request host: toolserver.org
• Request path: GET /~diberri/cgi-bin/templatefiller/index.cgi

The owner of this tool is: diberri [at] toolserver [dot] org.

Any ideas what to try? Basket of Puppies 13:51, 20 August 2009 (UTC)

Yeah... I have just discovered that it has been down for 2 days... Its author (User:diberri) says he will try to fix it as soon as possible. Lets wait a few days; it is worth it.--Garrondo (talk) 14:00, 20 August 2009 (UTC)

Merging and generalizing?

I know nothing about this problem. However, looking at cerebrospinal fluid leak I found only a stub. On the other hand there is probably a lot of overlapping between generally cerebrospinal fluid leak and the spontaneous one in most sections (diagnosis?, treatment?, complications?), while main difference is only in the causes section. Additionally most people is going to search for "cerebrospinal fluid leak" rather than specifically spontaneous. It may be a good idea to merge both articles specifying the differences when appropiate... I know it will be hard work, and difficult at the first moment reaching good article status, in the long run may probably benefit the article. Bests.--Garrondo (talk) 14:15, 20 August 2009 (UTC)

Howdy, Garrando. I've been trying to get my cowgirl on! There was a discussion a few months ago about CSF leak and spontaneous CSF leak. There discussion then (and I think consensus) was to keep them as separate articles. The reasons were pretty basic- spontaneous leak and traumatic csf leak are two very different condition with two very different causes and often two very different treatments. The number of peer-reviewed journal articles about spontaneous CSF leak lead credence to the position that each is separately notable and deserving of its own article. I feel that after we get this article up to GA status I'd like to begin heavily editing the CSF leak article, which will likely focus on traumatic/injury based CSF leak. I hope you agree. :) Basket of Puppies 15:36, 20 August 2009 (UTC)

I do not have to agree or disagree... I am no expert as I said, and it simply looked like a logical proposal.Bests.--Garrondo (talk) 15:38, 20 August 2009 (UTC)

Copyedit

A few remaining issues:

• The names given for the affected nerve complexes (Symptoms section) are inconsistent—some numbers, some names, some both. I'd prefer to see them all listed by their proper names. If you must give the numbers too, please do it for all of them (although I think that would be overkill).  Done Basket of Puppies 02:06, 28 August 2009 (UTC)

I will get to work on this immediately. Basket of Puppies 00:43, 28 August 2009 (UTC)

• "the facial nerve (the ninth (IX) cranial nerve)" - the facial nerve, I believe, is the seventh, which I think is what you mean to say here. Done Basket of Puppies 02:06, 28 August 2009 (UTC)

You are absolutely correct! Correcting... Basket of Puppies 00:43, 28 August 2009 (UTC)

• "A 2003–2004 Emergency Room-based study indicated that spontaneous CSF leak resulting in spontaneous intracranial hypotension in 5 patients per 100,000." - I couldn't figure out what this sentence is supposed to say, so I went to the cited source. I wasn't able to find anything at this source to support the statement (or the next one, cited to the same source, about the female:male ratio). Have you accidentally cited the wrong source here, or am I missing it? Either way, not clear what you are trying to say here, and from whence it came. Done Basket of Puppies 02:06, 28 August 2009 (UTC)

I think this is the case of putting in the wrong ref. I am searching for the correct one. Basket of Puppies 00:43, 28 August 2009 (UTC)

• I have some issues with the lengthy quote in the last citation. It should not be necessary to include such a long quote; if the information is helpful, write it in your own words—and put it right in the article text, not buried in a citation. If you feel a need to quote part of the journal article to verify a point, please make sure the quote is free of typographical errors ("in 193845"?) and copy/paste relics such as footnote numbers and line-break hyphens from the original article.

Hope this helps! Maralia (talk) 21:25, 27 August 2009 (UTC)  Not doneKind of done! I fixed the formatting and sentence structure issues. The full quote remains. Do you think we can move a few lines of the quote into the body of the article and then keep just the bare reference? Basket of Puppies 02:28, 28 August 2009 (UTC)

I was wondering about this. Perhaps I'll copy and paste part of the quote in and you can provide feedback and editing of it? Basket of Puppies 00:43, 28 August 2009 (UTC)

I hope you don't mind if I reply inline, above. Basket of Puppies 00:43, 28 August 2009 (UTC)

The changes are an improvement; thanks. I have made a few more minor copyediting tweaks. Regarding the quote, we could certainly retain a few lines as a direct quote and move it into the body. At present, though, the quote is so long that I can't fathom which part(s) you'd like to keep. Let me know and I'll offer another opinion. Maralia (talk) 02:36, 28 August 2009 (UTC)

I am so happy we're making great progress with this article! Thanks, Maralia! Regarding the history section- do you think this edit might be a good start? Basket of Puppies 03:13, 28 August 2009 (UTC)

Well, read in context, it's almost entirely redundant with the rest of the text in the section. What, exactly, are we trying to add by including the quote? Maybe I'm missing something here. Maralia (talk) 03:52, 28 August 2009 (UTC)

Right then, I've done a bigger rewrite. Tried to set it up in an intro, content, conclusion style format. Whaddya think? Basket of Puppies 05:28, 28 August 2009 (UTC)

That's much less redundant, but it still feels like wussing out to rely on so much quotation. I'm working on obtaining some additional sources; will have more suggestions soonish. Maralia (talk) 03:02, 29 August 2009 (UTC)

Arbitrary section break

Here's where I am at the moment:

1. The lengthy quote in History does not appear to be from the paper that is cited. Can you redirect me to the proper source? I am particularly interested in tracking down the vaguely mentioned previous reports 'in the French literature'.
2. Only one of the citations for the sources used in the article actually lists the authors' names. Can you add the authors' names, please?
3. I have acquired 6 or 8 additional papers, focusing on reviews rather than primary sources. I hope these will turn out to be helpful, although I haven't made it through them all yet. What I've read so far gives me the impression that this article falls short of completeness as yet. (I must beg off on specifics at the moment, as the research is over a week old in my illness-addled memory, but I do remember: hearing loss as a main presenting symptom; incessant mention of associated meningitis risk; fairly extensive coverage of other surgical approaches; and a strong predisposition for spontaneous leaks to occur on the right side.) I can give you a list of what I'm looking at, if you'd like to read them too.

Thanks for being so patient with me. Maralia (talk) 03:13, 11 September 2009 (UTC)

Regarding #1, the source that is cited is indeed the correct one. I just double checked. You may need to get the entire paper, which I would be happy to email you the PDF. Else you can attempt to get it from online sources or your local library. Regarding #2, I had thought it was common to simply write "et al" after the first author. #3, not a problem. Take your time. Basket of Puppies 03:24, 11 September 2009 (UTC)

On #1: I did access the full paper, as best I could tell. Could you quote, say, the beginning of just the first and last sentences of the paper so I can figure out the problem? #2: When I look at the References section, none of the citations lists any author name with the exception of the Schaltenbrand paper. Maralia (talk) 03:34, 11 September 2009 (UTC)

On #1, look at the paper under "Historical Aspects". It's the second sentence. #2, I'll work on fixing the references. Basket of Puppies 05:27, 11 September 2009 (UTC)

Re #1: I was looking at a full paper—but it wasn't the right one. At the given link for ref 15, there are three links to PDFs; two are the correct paper...and one is a paper that cites the correct paper. This is really not my week, I tell you! I'll be away overnight tomorrow, but should be back in business by Monday. Printing some of these papers to take with me. Maralia (talk) 02:26, 12 September 2009 (UTC)

using cite pmid for multiple refs?

Howdy, folks. I am converting most all of the refs over to the {{cite pmid}} template, but am confused about one thing- how do I link multiple statements to the single reference? I know we did this the manual way by using <ref name="blahblah> and that got the a,b,c,d,etc listing. For now I've simply redone the cite pmid template a few times, but thought it would look better the "old" way. Any ideas? Basket of Puppies 09:48, 24 September 2009 (UTC)

Hehe, figured it out. Would anyone mind checking my ref work? I'd sincerely appreciate it. Basket of Puppies 10:08, 24 September 2009 (UTC)

New article on imaging

Once it gets on PubMed, I am going to include this article in the text. Note to self, use the PMID cite template. Basket of Puppies 17:00, 1 December 2009 (UTC)

Diberris tool now works properly. It is a great tool to cite journal articles.

History unclear

I found this hard to understand: "Spontaneous CSF leaks have been described by notable physicians and reported in medical journals dating back to the 1800s. Among them were Georges Schaltenbrand and a French medical journal." Schaltenbrand is a 20th century writer. Is the French journal from the 1800s? Am exact year might be better.--agr (talk)

Dear agr, in the blockquote of the history section it stated that the condition was described in the late 1800s by a French journal. "A few decades earlier the same syndrome had been described in the French literature as “hypotension of spinal fluid” or “ventricular collapse.” " I hope this clears it up. Sorry for the confusion! Basket of Puppies 17:29, 15 December 2009 (UTC)

At the least, the article should say "late 1800s", but even then the construction would be awkward. If you're looking for GA, I'd lose the blockquote and paraphrase Its contents.--agr (talk) 21:18, 15 December 2009 (UTC)

GA Review 3

This review is transcluded from Talk:Spontaneous cerebrospinal fluid leak/GA3. The edit link for this section can be used to add comments to the review.

Reviewer: MisterWiki talk contribs 01:41, 30 December 2009 (UTC)

GA review (see here for criteria)

1. It is reasonably well written.

   a (prose): b (MoS):

   The prose actually needs some work. Unexperienced persons without knowledge of medicine or that kind of things maybe will not understand the article. That's why it needs some work. That's why Simple Wikipedia exists.

2. It is factually accurate and verifiable.

   a (references): b (citations to reliable sources): c (OR):

   Well referenced and is verifiable.

3. It is broad in its coverage.

   a (major aspects): b (focused):

4. It follows the neutral point of view policy.

   Fair representation without bias:

5. It is stable.

   No edit wars, etc.:

6. It is illustrated by images, where possible and appropriate.

   a (images are tagged and non-free images have fair use rationales): b (appropriate use with suitable captions):

   The captions are fine, and the image licensing issues too.

7. Overall:

   Pass/Fail: The article is fine. BoP has done a great job on the page. I think the article deserves to be a GA.

Unusual technical (?) term

Congrats on achieving GA, Mr. Puppies! I have a question which I hope won't seem foolish. In the archived peer review [1] there's a table captioned "Symptoms resulting from nerve fuckage." Nerve fuckage is a phrase I haven't encountered before. Is it one of those fancy-shmancy terms doctors learn in medical school? Google and other searches have been fruitless. I anxiously await enlightenment on the entymology this enigmatic yet eerily endearing epidural epithet. (signed) Perplexed in Peoria [aka EEng (talk) 18:11, 7 February 2010 (UTC)]

I think it was just a sort of placeholder term. I think the reviewer just wanted to give a suggestion for making the article easier to follow, and so used that highly non-technical term as a placeholder. NativeForeigner ^Talk/_Contribs 18:15, 7 February 2010 (UTC)

I perceive you're proposing it's a parameterizing placeholder? Perfect! (signed) Previously Perplexed in Peoria [aka EEng (talk) 18:21, 7 February 2010 (UTC)]

Brief Comments

Some quick comments for your consideration.

• MOS:IMAGE states that images should not sandwich text, as is the case for the Diagnosis section.
• I personally dislike the splitting of this article into such small sections.
• Also not a fan of image placement in general, especially File:Epidural blood patch.svg.
• Five references for For this reason, the SCSFLS is referred to as CSF hypovolemia as opposed to CSF hypotension. is a tad excessive. (Note that this is not policy)

That's all for now. ɳOCTURNEɳOIR _{talk // contribs} 16:29, 21 July 2010 (UTC)

Regarding small sections: the reason is WP:MEDMOS and the sections recommended for disease articles.--Garrondo (talk) 07:44, 22 July 2010 (UTC)

Regarding the 5 refs for hypovolemia vs hypotension, there is a large amount of confusion in the medical community regarding this and it is important to demonstrate that a large number of studies have concluded hypovolemia and not hypotension is the culprit. Basket of Puppies 18:58, 22 July 2010 (UTC)

Non-PMID references and their formatting

In reply to a concern brought up on the FAC page regarding formatting of non-PMID references, I'll go through them here and try to make sure they are consistent.

• 6. Greenberg, Mark (2006). Handbook of neurosurgery. New York, NY: Thieme Medical Publishers. p. 178. ISBN 0865779090. Retrieved 18 December 2009.
  • <ref name="Greenberg2006">{{cite book|author=Mark S. Greenberg|title=Handbook of neurosurgery|url=http://books.google.com/books?id=ExHcxxufG8sC&pg=PA178|accessdate=8 November 2010|year=2006|publisher=Thieme|isbn=9783131108869|pages=178–}}</ref>

• 7. Walsh & Hoyt (2005). Walsh and Hoyt's clinical neuro-ophthalmology, Volume 3. Baltimore, MD: Williams & Wilkins. p. 1303. ISBN 0683060236. Retrieved 18 December 2009.
  • <ref name="MillerHoyt2005">{{cite book|author1=Neil R. Miller|author2=William Fletcher Hoyt|title=Walsh and Hoyt's clinical neuro-ophthalmology|url=http://books.google.com/books?id=ATTlVWi3mvwC&pg=PA1303|accessdate=8 November 2010|year=2005|publisher=Lippincott Williams & Wilkins|isbn=9780781748117|pages=1303–}}</ref>
• 22. Schuenke, Michael; Schumacher, Schulte, Lamperti, Ross, Wesker (2007). Head and neuroanatomy. New York, NY: Thieme. p. 194. ISBN 3131421010. Retrieved 21 December 2009.
  • <ref name="SchuenkeSchumacher2007">{{cite book|author1=Michael Schuenke|author2=Udo Schumacher|author3=Erik Schulte|coauthors=Edward D. Lamperti, Lawrence M. Ross|title=Head and neuroanatomy|url=http://books.google.com/books?id=Y0-Rf_m7xj4C|accessdate=8 November 2010|year=2007|publisher=Thieme|isbn=9783131421012}}</ref>

So it looks like there are three non-PubMed references. Now to figure out if they are formatted differently from each other... Basket of Puppies 17:07, 7 November 2010 (UTC)

Copied from FAC: If they are books you can also use diberri's tool: you paste the isbn and gives you a citation on the same style that pmid references.--Garrondo (talk) 20:21, 7 November 2010 (UTC)

{{helpme}} I can't seem to get ref #6 to work properly. It keeps giving an error and I am unsure where the problem lays. Can you help me? Basket of Puppies 03:10, 8 November 2010 (UTC)

({{helpme}} is for use on your own talk page, but no worries.) Ref 6 doesn't seem to have been defined elsewhere; you need to have another <ref name="Handbook of neurosurgery">etc.</ref> first. /ƒETCHCOMMS/ 03:31, 8 November 2010 (UTC)

Fixed. Good luck with the FAC, Basket of Puppies. Diego Grez (talk) 03:38, 8 November 2010 (UTC)

Of course! Thank you for the speed and expert help! Basket of Puppies 03:45, 8 November 2010 (UTC)

Actually I didn't fix anything. It was a bot who did it. :-P I wonder if you do even remember me. I reviewed this article and passed it to GA. Diego Grez (talk) 03:50, 8 November 2010 (UTC)

Quotes from secondary source

Below is the section from Victor and Adams Principals of Neurology 8th ed on CSF leak.

P541 of Victor and Adams Principals of Neurology 8th ed Intracranial Hypotension Lumbar Puncture Headache (See also page 159) This is a well-known phenomenon, attributable to a lowering of ICP by leakage of CSF through the needle track into the paravertebral muscles and other tissues. Once begun, the headache may last for days or, rarely, even weeks. Most characteristic is the relation of the headache to upright posture and its relief within moments after assuming the recumbent position. Actually, the syndrome includes more than headache. There may be pain at the base of the skull posteriorly and in the back of the neck and upper thoracic spine, stiffness of the neck, and nausea and vomiting. At times the signs of meningeal irritation are so prominent as to raise the question of post– lumbar puncture meningitis, although lack of fever usually excludes this possibility. In addition to a low or unmeasurable CSF pressure if another spinal tap is performed (the CSF pressure is found to be in the range of 0 to 60 mmH2O), there are occasionally a few to a dozen white cells in the CSF, which may further raise concern of meningitis. In the infant or young child, stiffness of the neck may be accompanied by irritability, unwillingness to move, and refusal of food. If the headache is protracted, recumbency still reduces it, but a feeling of dull pressure may remain, which the patient continues to report as pain. Many patients also report that shaking the head produces a cephalic pain. Occasionally there will be a sixth nerve palsy or a self-audible bruit from turbulence in the intracranial venous system. It has been recognized that low CSF pressure is associated on the MRI with prominent dural enhancement by gadolinium (Fig. 30-4)—and, when the syndrome is protracted and severe, there may be small subdural effusions (see below, under “Spontaneous Intracranial Hypotension”). The use of a 22- to 24-gauge needle and the performance of a single clean (atraumatic) tap seemingly reduces the likelihood of a post–lumbar puncture headache, as discussed in Chap. 2. A period of enforced recumbency, though widely practiced as a means of preventing headache, probably does not lessen its incidence (Carbaat and van Crevel). The ingestion of large volumes of fluids and the infusion of 1000 to 2000 mL of 5% glucose are usually recommended but are of uncertain benefit. The most dependable treatment is a “blood patch” (spinal epidural injection of a few milliliters of the patient’s own blood). At least 75 percent of patients are thus relieved of the headache, according to Safa-Tisseront and colleagues; they report that after a second injection, improvement is effected in 97 percent. Many patients have transient back or radicular pain (sciatica) following the blood patch. Curiously, the headache is often relieved almost immediately even if the blood is injected at some distance from the original puncture (although the procedure is usually done at the same level as the previous spinal tap). Moreover, the volume of blood injected, usually about 20 mL, is not related to the chances of success. The mechanism of this rapid improvement may not simply be the plugging of a dural leak. A number of patients fail to benefit or have only transient effects; it is then unclear whether repeating the procedure is helpful. The administration of caffeine-ergotamine preparations or intravenous caffeine may also have a salutary though temporary effect on the headache. The addition of analgesic medication is required if the patient must get up to care for himself or to travel. In protracted cases, patience is called for, since most headaches will resolve in 2 weeks or less. As to mechanism, Panullo and colleagues have shown that there is a downward displacement of the upper brainstem and posterior fossa contents when the patient assumes the upright position; but, as pointed out in Chap. 17, only rarely are there associated signs of brain herniation, the exceptions being some of the unusual cases discussed below. Miyazawa and colleagues have forwarded the interesting findings that hypovolemia of the CSF, rather than lowered pressure, is the cause of downward displacement of the brain and dilation of cerebral and spinal epidural veins. They propose that the buoyancy provided by the spinal fluid is lost in these cases. Aside from the headaches, there are few adverse effects of

lumbar puncture; these are described in Chap. 2.

and

p542-543 Spontaneous Intracranial Hypotension This is a less well known syndrome, in which the same problem of low pressure as that which follows lumbar puncture occurs after straining, a nonhurtful fall, or for no known reason. The cardinal feature is orthostatic headache and only rarely are there other neurologic complaints such as diplopia from sixth nerve palsy or a self-audible bruit. In these cases the CSF pressure is low (60 mmH2O or less) or not measurable; the fluid may contain a few mononuclear cells but is most often normal. A few cases have presented with stupor as a result of downward transtentorial displacement of the diencephalic region (Pleasure et al) or an upper cervical myelopathy caused by downward deformation and displacement of the spinal cord (Miyazaki et al). In many such patients, there has been a tear in the delicate arachnoid surrounding a nerve root, with continuous leakage of CSF. The site of the leak is difficult to ascertain except when it occurs into the paranasal sinuses (CSF rhinorrhea). In a series of 11 patients with spontaneous intracranial hypotension, a putative leak was found by radionuclide cisternography or CTmyelography (the preferred procedure) in the cervical region or at the cervicothoracic junction in 5 patients, in the thoracic region in 5, and the lumbar region in 1 (Schievink et al). In the patients who underwent surgical repair, a leaking meningeal diverticulum (a so-called Tarlov cyst) was found and could be ligated. This seems to be the most common cause. A blood patch, as described above, may also be useful and should be attempted before resorting to surgery. Recumbency for a few days thereafter permits the pressure to build up, and there has been no recurrence in the cases that we have encountered. Others, however, have reported repeated episodes of orthostatic headache. As noted above, a helpful diagnostic sign is prominent dural enhancement with gadolinium on the MRI (Fig. 30-4), a phenomenon attributed by Fishman and Dillon to dural venous dilatation; this finding may extend to the pachymeninges of the posterior fossa and the cervical spine. According to Mokri and colleagues, biopsy of the dura and underlying meninges in these cases shows fibroblastic proliferation and neovascularity with an amorphous subdural fluid. There may be subdural effusions and mass effect, either on the cerebral convexities, temporal lobes, optic chiasm, or cerebellar tonsils. Using ultrasound, Chen and colleagues have also described an enlarged superior ophthalmic vein and increased blood flow velocity in this vessel, both of which normalize after successful treatment. Rarely, a case of intracranial hypotension becomes chronic; the headache is then no longer responsive to recumbency. Mokri and colleagues have also made the point that orthostatic headache and diffuse pachymeningeal enhancement on MRI may occur in the presence of normal CSF pressures; observation of these characteristic features should prompt a search for the site of CSF leakage despite the normal pressure. The use in hydrocephalus of a one-way shunt valve may be complicated by a syndrome of low CSF pressure. Reference has already been made to this syndrome and to the slit ventricles in children who have been treated for hydrocephalus. Usually the valve setting is too low, and readjustment to maintain a higher pressure is corrective. Also appropriate to mention here are CSF leaks that occur after cranial, nasal, or spinal surgery. These give rise to some of the most intractable low-pressure syndromes and must be investigated by radiologic and nuclide studies in order to establish the site of leakage. Several such leaks in our experience have been intermittent, adding to the difficulty in diagnosis.

and for citing purposes

{{cite book |author=Victor, Maurice; Ropper, Allan H.; Adams, Raymond Delacy; Brown, Robert F. |title=Adams and Victor's principles of neurology |publisher=McGraw-Hill Medical Pub. Division |location=New York |year=2005 |pages=541-543 |isbn=0-07-141620-X |oclc= |doi= |accessdate=}}

Basket of Puppies 06:16, 3 January 2011 (UTC)

Comments

First of all let me say that the article has clearly improved since FAC. Even so I feel there is still a lot of work to do.

• A general comment on sources: Now we have many reviews in the article, so if something does not appear in any of them, and we include it it may be giving undue weight to some content.
• On the other hand it is always a good idea when you have many secondary sources to use one of the last ones. I see that you have used a lot Schievink 2000, when there is Schievink 2006 and Schievink 2008. Is there any reason for it? I do not say to change the references already in the article to the newest ones, but maybe it would be a good idea from now on to try to use the newest ones.
• In several places you overreference an statement, with 3 sources for a sentence in many cases and 7(!!!) in the classification section. Not only is it not helpful but on the contrary it difficults fact checking since it is much harder to go one by one through all the sources. I would recommend that you use only the best source, or at most two sources, for any statement. For example I would say that for the classification sentence PMID 10560599 in which the name is proposed and another more recent source such as the handbook of neurosurgery would be more than enough.--Garrondo (talk) 08:21, 5 January 2011 (UTC)

I promise to continue soon.--Garrondo (talk) 08:22, 5 January 2011 (UTC)

Fortunately these are all pretty easy to tackle. I am doing some travel now, including going to the Wikipedia campus ambassador event next week so I might be a bit delayed, but I will implement the above very soon. Thank you for the thoughtfulness of this all. Basket of Puppies 00:36, 7 January 2011 (UTC)

Been away for a few days at Campus Ambassador training so I've just had a moment to look. Schievink2008 resolves to PMID 18264665 which is not a review article but rather Absence of TGFBR2 mutations in patients with spontaneous spinal CSF leaks and intracranial hypotension. Regarding Schievink2006, this is a review article and summarizes everything in Schievink2000 so I'll be adding Schievink2006 to those already referenced to 2000. In the cases of overreferencing, I'll remove 2000 and just keep 2006. Basket of Puppies 05:55, 13 January 2011 (UTC)

I've added schievink2006 to all schievink2000. Regarding the overrefernceing in the classification section, I certain see how it's too much. At the same time I am concerned that removing any of the references would make this article less complete by not including reliable sources pertinent to the topic. Any suggestions on how to deal with that? Basket of Puppies 06:20, 13 January 2011 (UTC)

First of all in those places leave only reviews. Secondly: sources actually do not make the article more or less complete since they do not add content. What they do is to make more verifiable an article. A normal fact, needs only "normal" referencing so with a single (high quality) reference it would be more than enough. Best thing to do is pick the highest quality ones: you could take into account the journal impact factor, the depth of the review (sometimes the number of pages is a good indicator), the year of publication, if a source is open access is also a positive mark (at equal quality with other)...--Garrondo (talk) 07:37, 13 January 2011 (UTC)

I have been bold and eliminated the most clear cases (all non-reviews) in the over-referenced sentence in classification. I would still eliminate the 2 handbooks so as to leave only two refs. My reasoning is that usually access to handbooks is harder than to online articles. What do you think?--Garrondo (talk) 08:02, 13 January 2011 (UTC)

In this line: there is no point in leaving two reviews by the same author as sources for the same fact. In this case it neither adds content nor even verifiability: you are actually only showing that the author did not change his POV in 6 years :-)--Garrondo (talk) 07:22, 13 January 2011 (UTC)

Moreover regarding Schievinks: I think you have made a mistake as you have finally added "Schievink, W. I.; Gordon, O. K.; Hyland, J. C.; Ala-Kokko, L. (2008). "Absence of TGFBR2 mutations in patients with spontaneous spinal CSF leaks and intracranial hypotension". The Journal of Headache and Pain 9" as ref, which is clearly primary as you have already noted. I was referring to "a b c Schievink, W. I. (2008). "Spontaneous spinal cerebrospinal fluid leaks". Cephalalgia : an international journal of headache 28 (12): 1345–1356. doi:10.1111/j.1468-2982.2008.01776.x. PMID 19037970." which is marked as a review in pubmed.--Garrondo (talk) 07:37, 13 January 2011 (UTC)

While you fix refs: I feel the sentences Both cranial and spinal spontaneous CSF leaks cause neurological symptoms as well as spontaneous intracranial hypotension, diminished volume and pressure of the cranium. For this reason, the SCSFLS is referred to as CSF hypovolemia as opposed to CSF hypotension deserve some more explanation. I am no expert and in this sense I do not clearly understand why the first sentence is the reason for the second since there is both neurological symptoms and hypotension. I lay reader will probably need some lines explaining it with simple words. At least I do :-).--Garrondo (talk) 07:41, 13 January 2011 (UTC)

As a minor comment, MOS on images says that text should not be sandwiched by images, which occurs in the CT section. I believe best thing would be to leave only one of the two (probably better the machine), but you can also try to put both of them at right.--Garrondo (talk) 07:44, 13 January 2011 (UTC)

Going to the library tomorrow to get a copy of Schievink2008, just to make sure nothing major has changed since his 06 review article. I tended to most of the issues including the classification wording. I'll look at the images in a bit. What do you think? Basket of Puppies 07:28, 18 January 2011 (UTC)

I just got Schievink2008. Took weeks. Reading now. Basket of Puppies 04:21, 31 January 2011 (UTC)

I hope it is useful after all the effort it took you... As soon as you feel comments above have been addressed I would take another look at the article. Bests . On a side note I have seen your great success as embassador. Well done. --Garrondo (talk) 07:27, 31 January 2011 (UTC)

It was a very good read, actually. Not that much new, but I now have a secondary source for some things that only had primary. I'll go about adding that. Basket of Puppies 14:59, 31 January 2011 (UTC)

That is great news... Secondary sources is what we need.--Garrondo (talk) 15:15, 31 January 2011 (UTC)

And thank you for the compliments about the ambassador program. I am at the moment sitting in the commons of the Harvard Law School where I am about to meet with a professor whom I am "CAing" for. (CAing is the Wiki equivalent of being a TA.) I've made some additions to the article but more are necessary and I'll do those this week. Basket of Puppies 15:50, 31 January 2011 (UTC)

Alrighty, I've spent the past few hours on the article. Interested to read your assessment, when you have the time. Basket of Puppies 04:38, 1 February 2011 (UTC)

Definetely going in the right direction. The last reference seems to have been really useful, at least by the number of uses :-). The article probably has now all the best secondary available up to date. Next step would probably to reduce overreferencing, eliminating or reducing the use of unneeded primary refs: there are many places where there is already secondary refs in addition to primary, so primaries can be eliminated if the statement is fully supported by the the secondary source. Examples in the second section:

• Most people who develop SCSFLS feel a sudden onset of a severe and acute headache.[9][11][12]: Two secondary and one primary. Would be better to simply have the latest secondary, specially since 3 refs are by the same author.
• Other symptoms include severe dizziness and vertigo, facial numbness or weakness, double vision, a metallic taste in the mouth, nausea, and vomiting.[9][11]: Second is primary. If supported by first I would eliminate second.
• Orthostatic headaches can be incapacitating;[15][16] these symptoms can be sufficiently disabling to make those afflicted unable to work.[16][9][11][17]: 5 references for a sentence, 3 of them primary? Probably with one you can support the statement.
• Nerves that can be affected and their related symptoms are detailed in the table at right.[9][11][10][17]: The sentence has 4 references, but the 10 is also used in the table. With the latter probably enough.

--Garrondo (talk) 07:40, 1 February 2011 (UTC)

I have eliminated the simplest which was the use of a primary ref on genetics by Schievink.--Garrondo (talk) 07:45, 1 February 2011 (UTC)

I think these issues have been remedied minor by myself and mostly by you. Looking forward to the next step. Basket of Puppies 22:50, 1 February 2011 (UTC)

I still think that there is a lot of oversourcing and use of unneeded primary sources. What I corrected was only an example of a problem that exists all over the article. On the other hand it is true that right now most paragraphs are referenced to secondary sources. Easy way: eliminate all primary sources when they are supporting the same sentence than a secondary source (of course, as long as the secondary fully supports the statement). Nevertheless there are other issues that could also be improved:

• In general there is over-subsectioning, with many sections made of a single paragraph. This breaks the reading flow. I would eliminate subsections titles, since paragraphs inside a level two section already mark different "subsections"; unless they can be greatly expanded.
• Images in CT sandwich text, being this against MOS. Done
• It is not clear in its description the relevance of the lead image for the article. Done
• spontaneous intracranial hypotension in complications: why is it bolded? Done
• Roughly 20% of patients with SCSFLS exhibit features of Marfan syndrome, including tall stature, chest divot (arachnodactyly), join hypermobility and arched palate. However these patients do not exhibit any other Marfan syndrome presentations: Some internal linking would be great. Done

More to come as they are fixed; specially first one.--Garrondo (talk) 13:40, 2 February 2011 (UTC)

Regarding the oversectioning, I actually like it better. It helps the organization of the article, especially the fact that there are several schools of thought or methods to approach the various issues. Is there any way to keep it? Basket of Puppies 02:03, 14 February 2011 (UTC)

I'll doubt it. At FAC reviewers give great importance to style... I will not be able to give you additional hints for some time since I am really messed up with the Parkinson's disease FAC nomination.

Recently published articles to include

Several new articles have been published on this condition and they seem to warrant inclusion here. They are:

• PMID 21811806 Second-half-of-the-day headache as a manifestation of spontaneous CSF leak.
• PMID 21772804 Double skull base defects with primary spontaneous cerebrospinal fluid leaks in a single patient: temporal and sphenoid bones.
• PMID 21658029 Diagnostic Criteria for Headache Due to Spontaneous Intracranial Hypotension: A Perspective.
• PMID 21220378 Connective tissue disorders in patients with spontaneous intracranial hypotension.
• PMID 20974330 The utility of intrathecal fluorescein in cerebrospinal fluid leak repair.
• PMID 20562454 MRI with intrathecal gadolinium to detect a CSF leak: a prospective open-label cohort study.
• PMID 20157378 Spontaneous intracranial hypotension secondary to lumbar disc herniation.already used this one

I'll go about adding them. The most important I think is Diagnostic Criteria for Headache Due to Spontaneous Intracranial Hypotension: A Perspective which significantly upgrades the diagnostic criteria for this condition. Basket of Puppies 04:45, 23 August 2011 (UTC)

Duration

"It is likely that many mild cases remain undiagnosed, whereas other patients are incapacitated for years or decades and are unable to engage in any useful activity while being upright." Spontaneous spinal cerebrospinal fluid leaks WI Schievink published in Headache Currents December 2008. As a result of this I undid the duration edit. 76.118.223.82 (talk) 05:38, 17 April 2015 (UTC)

How does that contradict my edit, which clearly says symptoms can last years? The other version is misleading because it discusses only these apparently rare chronic cases, with no mention of the more numerous mild cases. The source I added, Spears (2014), states: "When dealing with SIH [spontaneous intracranial hypotension], some patients resolve in two weeks, while others continue to have headaches for several months or, rarely, even years." KateWishing (talk) 11:38, 17 April 2015 (UTC)

Your version needs to include both situations- some resolve quickly and others persist for years. Mine have persisted for 8 years now. 76.118.223.82 (talk) 20:47, 17 April 2015 (UTC)

You must have missed the second sentence in my version: "In rare cases, patients may suffer from unremitting symptoms for many years." KateWishing (talk) 03:23, 18 April 2015 (UTC)

You need to represent both studies. You also need to not remove cited material. That is a violation of policy. 76.118.223.82 (talk) 04:42, 19 April 2015 (UTC)

My edit is perfectly consistent with all sources, and does not remove any cited information. Although I deleted nothing, for future reference, removing cited material is not a violation of policy; see WP:ONUS. For the sake of compromise, I will change "rarely" to "less commonly." If you revert again, I will seek outside input. KateWishing (talk) 11:00, 19 April 2015 (UTC)

Just follow policy and don't remove cited material and you'll be OK. 76.118.223.82 (talk) 05:09, 21 April 2015 (UTC)

Being cited is not a magic talisman. Editorial judgment applies in all cases, and there is no need to include redundant sources for statements adequately covered by other sources. Guy (Help!) 09:38, 25 April 2015 (UTC)

Please read WP:MEDMOS, Guy/JzG. Science articles must be based in science. Thank you. 76.118.223.82 (talk) 05:28, 26 April 2015 (UTC)