Spontaneous intracranial hypotension: improving recognition and treatment strategies in the local setting

Abstract

We report a case of spontaneous intracranial hypotension with classic symptoms of orthostatic headache and acute presentation of subdural haematoma on computed tomographic scan. Conventional approach with conservative treatment was initially adopted. The patient's condition, however, deteriorated after 2 weeks, requiring surgical evacuation of the intracranial haemorrhage. We reviewed the clinical features of this disease and the correlated magnetic resonance imaging findings with the pathophysiological mechanisms, and described treatment strategies in the local setting. Subtle findings on initial computed tomographic scan are also reported which might improve pathology recognition. Spontaneous intracranial hypotension is not uncommonly encountered in Hong Kong, and physicians must adopt a high level of clinical suspicion to facilitate early diagnosis Spontaneous intracranial hypotension: improving recognition and treatment strategies in the local setting Case reportA 54-year-old man with no history of trauma was admitted to the Prince of Wales Hospital for headache of progressive severity accompanied by dizziness in August 2012. He had consulted the emergency room 4 weeks earlier for neck pain, and had an unremarkable computed tomographic (CT) scan of the brain (CTB). Further enquiry revealed an orthostatic component within the headache (worse in upright position and relieved within minutes of assuming supine posture), while admission CTB revealed interval development of bilateral 5 mmthick frontoparietal subacute subdural haematomas (SDHs) with disproportionate tightness of the basal cisterns. Cerebral magnetic resonance imaging (MRI) additionally demonstrated compression of the midbrain, but no caudal herniation of the cerebellar tonsils beyond the foramen magnum. Contrast study showed diffuse pachymeningeal enhancement, venous sinus distension, and prominent pituitary gland. Spinal MRI was unremarkable and MRI cisternography/myelography was negative for cerebrospinal fluid (CSF) leakage.The patient was advised complete bed rest

Lumbar epidural blood patch: An effective treatment for intracranial hypotension

“…[9] Radiologically, pathognomonic magnetic resonance imaging (MRI) findings of the brain include venous engorgement, diffuse dural thickening, and intracranial pachymeningeal gadolinium enhancement, reactive hyperemia of the pituitary gland, subdural collections, and hematomas, and brain sagging. [18] e finding of brain sagging includes a group of features, consisting of decreased dimensions of the suprasellar cistern, displacement of the suprasellar and perimesencephalic cistern, hindbrain herniation, and optic chiasma bowing. [22] Commonly, MRI cisternography or myelography may also be included in the workup of suspected SIH patients.…”