Posterior Reversible Encephalopathy Syndrome Secondary to CSF Leak and Intracranial Hypotension: A Case Report and Literature Review

Hammad, Tariq; DeDent, Alison; Algahtani, Rami; Alastal, Yaseen; Elmer, Lawrence; Medhkour, Azedine; Safi, Fadi; Assaly, Ragheb

doi:10.1155/2015/538523

Cited by 9 publications

(15 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Therefore, when diagnosing PDPH in obstetric patients, it is important to exclude other causes of headache, such as functional headaches. Less frequent complications of accidental dural puncture include reversible encephalopathy [111213], pneumocephalus [14], and subdural hematoma [1516]. Therefore, when neurological signs or changes in headache characteristics such as non-postural headache occur, serious etiologies should be excluded such as subdural hematoma, cerebral thrombosis, and reversible encephalopathy [17].…”

Section: Clinical Symptoms and Diagnosismentioning

confidence: 99%

Postdural puncture headache

Kwak

2017

Korean J Anesthesiol

131

134

View full text Add to dashboard Cite

Postdural puncture headache (PDPH) is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the technique used also affect the risk. Because PDPH can be incapacitating, prompt diagnosis and treatment are mandatory. A diagnostic hallmark of PDPH is a postural headache that worsens with sitting or standing, and improves with lying down. Conservative therapies such as bed rest, hydration, and caffeine are commonly used as prophylaxis and treatment for this condition; however, no substantial evidence supports routine bed rest and aggressive hydration. An epidural blood patch is the most effective treatment option for patients with unsuccessful conservative management. Various other prophylactic and treatment interventions have been suggested. However, due to a lack of conclusive evidence supporting their use, the potential benefits of such interventions should be weighed carefully against the risks. This article reviews the current literature on the diagnosis, risk factors, pathophysiology, prevention, and treatment of PDPH.

show abstract

Section: Clinical Symptoms and Diagnosismentioning

confidence: 99%

Postdural puncture headache

Kwak

2017

Korean J Anesthesiol

131

134

View full text Add to dashboard Cite

show abstract

“…In response to CSF loss and intracranial hypotension, the body may compensate by increasing cerebral perfusion pressure. 5 In extreme states, this hyperperfusion could result in autoregulatory failure consistent with the classic model of PRES. Furthermore, according to the Monro-Kellie doctrine, the cranium contains a fixed volume of brain tissue, blood, and CSF.…”

Section: Oy-stersmentioning

confidence: 64%

“…2 Of note, unlike these classic theories, the pathophysiology of PRES during episodes of intracranial hypotension has been associated with both arterial and venous dysfunction. [4][5][6] Regarding arterial abnormalities, several cases suggest that downward displacement of the brain in SIH, along with the subsequent release of chemical and neurogenic factors, can cause transient multifocal vasoconstriction of large and medium-sized arteries. 4,7 This segmental arterial sclerosis, known as reversible cerebral vasoconstriction syndrome (RCVS), results in transient episodes of ischemia and vasogenic edema.…”

Section: Oy-stersmentioning

confidence: 99%

“…9 We found only 3 case reports of intracranial hypotension and PRES following CSF leak that have directly cited venous dysfunction in the pathogenesis of PRES. [4][5][6] Two mechanisms could explain this phenomenon. First, brain perfusion depends on both systemic mean arterial pressure (MAP) and intracranial pressure (ICP), the difference of which determines cerebral perfusion pressure (CPP): CPP 5 MAP 2 ICP.…”

Section: Oy-stersmentioning

confidence: 99%

“…We also recommend tight blood pressure control in patients with CSF leak because they may be more susceptible to developing PRES with normal or slightly elevated values, as evidenced in this case. 5 …”

Section: Oy-stersmentioning

confidence: 99%

See 2 more Smart Citations

Pearls & Oy-sters: Spontaneous intracranial hypotension and posterior reversible encephalopathy syndrome

2016

View full text Add to dashboard Cite

Pearls & Oy-sters: Spontaneous intracranial hypotension and posterior reversible encephalopathy syndrome PEARLS• Although rare, cases of posterior reversible encephalopathy syndrome (PRES) secondary to CSF leak and intracranial hypotension have been documented in the literature.• The pathogenesis of PRES in these settings has been associated with both arterial and venous cerebrovascular dysfunction. OY-STERS• PRES should be suspected in patients with CSF leak who continue to experience headache, visual changes, and altered mentation despite conservative management.• The mainstay of treatment involves resolution of the CSF leak, typically with an autologous epidural blood patch.CASE REPORT A 65-year-old woman with no significant medical history was brought to the emergency room after experiencing 2 weeks of band-like occipital headaches and 2 days of progressive mental status changes. Her neurologic examination was significant for decreased alertness, disorientation to time, confabulation, loss of recent and remote memory, diffuse hyperreflexia, and a left Hoffmann sign. MRI of the brain with contrast showed bilateral subdural hygromas, diffuse enhancement of the dura mater, with mild sagging of the brainstem suggestive of intracranial hypotension (figure 1, A and B). MRI of the spine showed a large collection of CSF in the lumbar epidural space ( figure 2A); however, the tear site was not identified. EEG also revealed generalized slowing with no evidence of seizure activity. Her mental status continued to deteriorate despite conservative measures such as aggressive hydration, caffeine intake, and bedrest in the Trendelenburg position. A head CT was ordered for worsening mental status and revealed symmetric hypoattenuation of the bilateral parasagittal occipital cortices consistent with PRES ( figure 2B), a finding that was not present on the initial MRI. She then received an emergent lumbar epidural blood patch, resulting in dramatic improvement in mental status several hours later. She was discharged without any focal neurologic deficits. An MRI performed 10 days later revealed no evidence of PRES in the occipital region. An MRI of the lumbar spine performed 5 weeks later showed resolution of the fluid collection (figure 3).DISCUSSION Spontaneous intracranial hypotension (SIH) is a known neurologic condition characterized by occipital headaches, neck stiffness, and altered mentation that results from leakage of CSF through a structural break in the meninges. Distinct abnormalities on MRI support the diagnosis, including diffuse meningeal enhancement, subdural fluid collections, engorgement of the dural sinuses, and downward displacement of the brain that can result in compression of vital structures (figure 1, A and B). Stupor and coma, for example, have been linked to compression of the diencephalon. 1 While our patient's altered mental status was initially attributed to brain sagging, her clinical deterioration was complicated by a transient occipital hypodensity concerning for PRES (figure 2B). Although rare...

show abstract