Spontaneous intracranial hypotension and immediate improvement following epidural blood patch placement demonstrated by intracranial pressure monitoring

✓ The presentation of spontaneous intracranial hypotension (SIH) can be associated with various clinical and neuro-imaging features that may impede a rapid diagnosis of this entity. The authors report the case of a patient who presented with bilateral third cranial nerve palsies and bilateral subdural hematomas. Intracranial pressure monitoring proved to be useful in the diagnosis and management of SIH in this patient.

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Intracranial Hypotension with Coma: Microsurgical Repair of a Spinal Ventral Dural Tear and Drainage of Subdural Hematoma with Intracranial Pressure Monitoring

World Neurosurgery ◽

10.1016/j.wneu.2018.07.148 ◽

2018 ◽

Vol 118 ◽

pp. 269-273 ◽

Cited By ~ 5

Author(s):

Keisuke Takai ◽

Makoto Taniguchi

Keyword(s):

Intracranial Pressure ◽

Subdural Hematoma ◽

Intracranial Hypotension ◽

Intracranial Pressure Monitoring ◽

Dural Tear ◽

Pressure Monitoring

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Intracranial Hypotension with Multiple Complications: An Unusual Case Report

Case Reports in Neurological Medicine ◽

10.1155/2013/913465 ◽

2013 ◽

Vol 2013 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Swetha Ade ◽

Majaz Moonis

Keyword(s):

Case Report ◽

Subarachnoid Hemorrhage ◽

Intracranial Hypotension ◽

Epidural Blood Patch ◽

Spontaneous Intracranial Hypotension ◽

Artery Aneurysm ◽

Cranial Nerve Palsies ◽

Blood Patch ◽

Life Threatening ◽

The Brain

Background. Undiagnosed intracranial hypotension can result in several complications including subdural hematoma (SDH), subarachnoid hemorrhage (SAH), dural venous sinuses thrombosis (CVT), cranial nerve palsies, and stupor resulting from sagging of the brain. It is rare to see all the complications in one patient. Furthermore, imaging of the brain vasculature may reveal incidental asymptomatic small aneurysms. Given the combination of these imaging findings and a severe headache, the patients are often confused to have a primary subarachnoid hemorrhage.Case Report. We present a patient with spontaneous intracranial hypotension (SIH) who had an incidental ophthalmic artery aneurysm on MR imaging, and this presentation led to coiling of the aneurysm. The key aspect in the history “postural headaches” was missed, and this led to life threatening complications and unnecessary interventions. Revisiting the history and significant improvement in symptoms following an epidural blood patch resulted in the diagnosis of SIH.Conclusion. We strongly emphasize that appropriate history taking is the key in the diagnosis of SIH and providing timely treatment with an epidural blood patch could prevent potentially life threatening complications.

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Intracranial pressure monitoring in the posterior fossa: a preliminary report

Journal of Neurosurgery ◽

10.3171/jns.1989.71.4.0503 ◽

1989 ◽

Vol 71 (4) ◽

pp. 503-505 ◽

Cited By ~ 35

Author(s):

Robert H. Rosenwasser ◽

Laurence I. Kleiner ◽

Joseph P. Krzeminski ◽

William A. Buchheit

Keyword(s):

Intracranial Pressure ◽

Posterior Fossa ◽

Cerebrospinal Fluid Leak ◽

Early Postoperative Period ◽

Intracranial Pressure Monitoring ◽

Posterior Fossa Surgery ◽

Pressure Monitoring ◽

Content Type ◽

Cranial Nerve Palsies ◽

Fine Print

✓ Direct therapeutic drainage and intracranial pressure monitoring from the posterior fossa has never been accepted in neurosurgical practice. Potential complications including cerebrospinal fluid leak, cranial nerve palsies, and brain-stem irritation have been a major deterrent. The authors placed a catheter for pressure monitoring in the posterior fossa of 20 patients in the course of posterior fossa surgery: 14 patients with acoustic schwannomas, four with posterior fossa meningiomas, one with cerebellar hemangioblastoma, and one with a solitary cerebellar metastatic lesion. A Richmond bolt was also placed in the frontal area. Continuous monitoring of the supratentorial and infratentorial compartments was performed for 48 hours. During the first 12 hours the posterior fossa pressure was 50% greater than that of the supratentorial space in all patients (p < 0.01). Over the next 12 hours the supratentorial pressure was 10% to 15% higher than the posterior fossa pressures in all patients, and by 48 hours of monitoring the pressures had equilibrated. There was no mortality or morbidity referable to insertion of the posterior fossa catheter. The conclusions drawn from this study are that: 1) direct monitoring and drainage of the posterior fossa is safe and effective; and 2) within the early postoperative period, the supratentorial pressures failed to reflect what is taking place within the posterior fossa. The implications and advantages of direct posterior fossa monitoring in the postoperative patient are discussed.

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Typical MRI Features in Spontaneous Intracranial Hypotension: A Rare Cause of Headache

Nepalese Journal of Radiology ◽

10.3126/njr.v1i1.6324 ◽

2012 ◽

Vol 1 (1) ◽

pp. 45-51

Author(s):

N Hekha ◽

CC Tchoyoson Lim

Keyword(s):

Intracranial Hypotension ◽

Epidural Blood Patch ◽

Spontaneous Intracranial Hypotension ◽

Imaging Features ◽

Postural Headache ◽

Delay In Diagnosis ◽

Mri Features ◽

Blood Patch ◽

Csf Leakage ◽

Fluid Collections

Spontaneous CSF leakage from the spinal canal can give rise to spontaneous intracranial hypotension (SIH). Typically, these patients complain of orthostatic (postural) headache, have very low CSF pressure on lumbar puncture (LP) and usually respond to conservative treatment or by an epidural blood patch. The characteristic MRI features include subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperaemia and sagging of the cerebellar tonsils. Radiologists should recognize the typical clinical and imaging features of SIH and distinguish it from more sinister or malignant differential diagnosis, in order to prevent a delay in diagnosis or unnecessary surgical intervention, especially in resource-constrained situations in developing nations.DOI: http://dx.doi.org/10.3126/njr.v1i1.6324 Nepalese Journal of Radiology Vol.1(1): 45-51

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Comparisons of clinical characteristics, brain MRI findings, and responses to epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache: retrospective study

BMC Neurology ◽

10.1186/s12883-021-02279-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Gha-Hyun Lee ◽

Jiyoung Kim ◽

Hyun-Woo Kim ◽

Jae Wook Cho

Keyword(s):

Intracranial Hypotension ◽

Dural Puncture ◽

Epidural Blood Patch ◽

Brain Mri ◽

Spontaneous Intracranial Hypotension ◽

Vein Of Galen ◽

Mri Findings ◽

Post Dural Puncture Headache ◽

Straight Sinus ◽

Blood Patch

Abstract Background Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment. Methods We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus). Results A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02). Conclusions Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

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