Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension

Spectrum of subdural fluid collections in spontaneous intracranial hypotension

Object. Spontaneous intracranial hypotension is a noteworthy but commonly misdiagnosed cause of new daily persistent headaches. Subdural fluid collections are frequent radiographic findings, but they can be interpreted as primary rather than secondary pathological entities, and uncertainties exist regarding their optimal management. The authors therefore reviewed their experience with subdural fluid collections in 40 consecutive patients with spontaneous spinal cerebrospinal fluid (CSF) leaks and intracranial hypotension.

Methods. The mean age of the 26 female and 14 male patients was 43 years (range 13–72 years). Subdural fluid collections were present in 20 patients (50%); 12 of these patients (60%) had subdural hygromas alone, and eight (40%) had subacute to chronic subdural hematomas (SDHs) associated with significant mass effect. The subdural hygromas resolved within several days to weeks following treatment of the underlying CSF leak. Three patients with SDHs underwent evacuation of the hematoma prior to the establishment of the diagnosis of spontaneous intracranial hypotension, but the SDHs did not resolve until the underlying spinal CSF leak was treated. In the remaining five patients, the CSF leak was treated primarily and the SDHs resolved over a 1- to 3-month period without the need for evacuation.

Conclusions. Subdural fluid collections are common in spontaneous intracranial hypotension, varying in appearance from thin subdural hygromas to large SDHs associated with significant mass effect. These collections can be safely managed by directing treatment at the underlying CSF leak without the need for hematoma evacuation.

Céphalées de l’hypotension spontanée du liquide cérébro-spinal

Cerebrospinal fluid hypotension is a rare, incapacitating syndrome characterized by cerebrospinal fluid hypovolemia occurring in the absence of known dural tear. Severe orthostatic headache is the main symptom and clinical examination is usually normal. Magnetic resonance imaging shows the characteristic association of three signs: diffuse pachymeningeal gadolinium enhancement, sagging brain and bilateral subdural collections. Lumbar puncture is contraindicated. The single most effective treatment is lumbar epidural blood patch which cures over 50 percent of the patients and can be repeated in case of recurrence. The search for a dural tear is rarely necessary and surgical treatment is exceptionally required.

Zebra sign: cerebellar bleeding pattern characteristic of cerebrospinal fluid loss

✓ Supratentorial subdural hematoma is a well-known complication following spinal interventions. Less often, spinal or supratentorial interventions cause remote cerebellar hemorrhage (RCH). The exact pathomechanism accounting for RCH remains unclear, but an interventional or postinterventional loss of cerebrospinal fluid (CSF) seems to be involved in almost all cases. Hemorrhage is often characterized by a typical, streaky bleeding pattern due to blood spreading in the cerebellar sulci. Three different cases featuring this bleeding pattern following spinal, supratentorial, and thoracic surgery are presented. Possible pathomechanisms leading to RCH are discussed. Based on data from the underlying cases and the reviewed literature, the authors concluded that this zebra-pattern hemorrhage seems to be typical in a postoperative loss of CSF, which should always be considered on presentation of this bleeding pattern.

Spontaneous intracranial hypotension—A case report

Positional or orthostatic headache symptoms secondary to intracranial hypotension are usually seen as complications in patients after medical procedures, such as lumbar puncture. We describe a case of spontaneous intracranial hypotension (SIH) in a 43-year-old man without a previous history of headaches. He presented to the Emergency Department (ED) with a new-onset orthostatic headache without any history of recent medical procedure, such as lumbar puncture (LP). The ED evaluation included a normal neurologic examination and normal computed tomography (CT) scan of the brain. An LP showed low opening pressure, elevated protein, 46 RBCs and one lymphocyte. Subsequent evaluation with radionuclide cisternography confirmed a cerebrospinal fluid (CSF) leak in the area of the upper thoracic spine, and treatment with an epidural blood patch dramatically improved his symptoms. SIH is due to CSF leakage, usually in the area of the cervical or upper thoracic spine, often without a clear etiology. Conservative medical management including bed rest, oral hydration and caffeine intake is the usual first line treatment. An epidural blood patch is often a dramatically effective treatment that can be done once the presence and location of the leak is identified. Although mostly benign, this condition occasionally can be associated with the formation of clinically significant subdural fluid collections or hematomas. SIH is an increasingly recognized cause of headache.

Intérêt du blood-patch pour le traitement de l’hypotension intracrânienne spontanée

OBJECTIVE

Spontaneous intracranial hypotension (SIH) is a rare syndrome. It is due most often to a spinal meningeal leak. Symptoms due to SIH are often difficult to treat and epidural blood-patch (BP) has been proposed. The aim was to evaluate the effects and the problems associated with lumbar blood-patch to treat SIH.

STUDY DESIGN

Case series.

PATIENTS AND METHODS

The diagnosis of SIH was made in six consecutive patients on clinical signs and radiological findings (CT-scan and MRI). A lumbar BP (L1-L2 level) was performed as soon as possible after diagnosis. A maximum of three procedures was allowed in case of failure of the initial BP.

RESULTS

BP was effective and well tolerated for five patients (3 immediately after BP, 2 others patients needed 2 and 3 BP). In one patient, an incomplete response was observed and was related to a large CFS leak diagnosed by CT-myelogram.

CONCLUSION

When the diagnosis of spontaneous intracranial hypotension is confirmed, a repeated blood patch lumbar procedure can be efficient to treat these patients.

Spontaneous low cerebrospinal pressure/volume headaches

The majority, if not all, of the cases of spontaneous intracranial hypotension result from spontaneous cerebrospinal fluid (CSF) leaks. The disorder has a broad clinical and imaging spectrum with substantial variability in clinical and imaging features, in CSF findings, and in response to treatment. Headache is the most common symptom and is typically orthostatic, but with chronicity the orthostatic features may blur into a chronic, lingering headache. Other clinical features include neck pain, nausea, emesis, interscapular pain, diplopia, dizziness, change in hearing, visual blurring, radicular upper extremity symptoms, and a variety of other, but much less common, manifestations. The most common imaging feature is diffuse pachymeningeal gadolinium enhancement. Other manifestations include imaging evidence of sinking of the brain, subdural fluid collections, enlargement of the pituitary, engorgement of venous sinuses, and engorgement of epidural venous plexus. CSF opening pressure is typically low and CSF analysis may be normal or show increased protein concentration and a primarily lymphocytic pleocytosis. No longer can the entity be simply equated with post-spinal puncture headaches. The pathogenetic core and the independent variable is decrease in CSF volume, whereas clinical imaging and CSF findings, including CSF opening pressures, are all variables dependent on the loss of CSF volume. Many patients respond well to treatment, but some present stubborn therapeutic challenges. A subgroup of patients with orthostatic headaches is gradually recognized who have disorders other than CSF leaks.