Management of patients with spontaneous intracranial hypotension causing altered level of consciousness: report of two cases and review of literature

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

Neuroimaging in the diagnosis and treatment of intracranial pressure disorders

OBJECTIVE

To review the clinical features, proposed pathophysiology, and the role of medical imaging in the diagnosis and treatment of idiopathic intracranial hypertension and spontaneous intracranial hypotension.

METHODS

The authors conducted a narrative review of the current literature on intracranial hypertension and hypotension syndromes, with a focus on imaging findings and role of neurointerventional radiology as a therapeutic option for these pathologies.

RESULTS

Idiopathic intracranial hypertension commonly presents in obese women of childbearing age, being headache and papilledema the main clinical manifestations. Characteristic radiological findings consist of increased cerebrospinal fluid around the optic nerve, partially empty sella turcica and stenosis of the transverse sinuses. Transverse sinus stenting is a treatment alternative that has proven valuable utility in the recent years. Spontaneous intracranial hypotension in most of cases presents with orthostatic headache and has predilection for female population. The typical radiological features in the brain consist of subdural fluid collections, enhancement of the dura, engorgement of the venous structures, pituitary enlargement, and sagging of the brain. In this pathology, a cerebrospinal fluid leak in the spine associated with a defect in the dura, meningeal diverticulum, or a cerebrospinal fluid-venous leak must be actively ruled out.

CONCLUSIONS

Neurologic complaints secondary to changes in intracranial pressure exhibit certain clinical features that in combination with fairly specific radiological patterns allow a highly accurate diagnosis. The diverse specialists in neurosciences should be aware of the multiple image modalities in the study of these syndromes as well as the treatment alternatives by neurointerventional radiology.

Intracranial Hypotensive Crisis From an Insidious Spinal Cerebrospinal Fluid-Venous Fistula: A Case Report

BACKGROUND AND IMPORTANCE

Progressive episodic spells of altered levels of consciousness, often advancing to include paroxysmal autonomic instability, may be indicative of a diencephalic dysfunction underlying spontaneous intracranial hypotension (SIH). A rare, and often indolent, etiology may be spinal cerebrospinal fluid (CSF) leak-an elusive diagnosis, especially in cases of CSF-venous fistula (CVF) that are often missed on routine computed tomography (CT) myelography and magnetic resonance imaging (MRI).

CLINICAL PRESENTATION

We report an unusual case of a 50-yr-old woman who presented with rapidly progressive cyclical, self-resolving episodes of altered mentation and decreased arousal later in the day. Scrutiny of serial brain MRIs led to a diagnosis of SIH, with severe downward diencephalic and brain stem displacement-resulting in cerebral aqueduct occlusion with obstructive hydrocephalus. Initial clinical improvement occurred with CSF diversion, but the patient quickly deteriorated-developing diencephalic spells, including extensor posturing and severely depressed levels of consciousness. Clinical improvement was seen with stopping CSF diversion and Trendelenburg-positioning. After intensive spinal imaging, dynamic CT myelography identified a left T10 nerve root diverticula and CSF-venous fistula. Surgical obliteration resulted in rapid, profound neurological improvement, and ultimately full neurological recovery by 1 yr.

CONCLUSION

In our patient, worsening episodes of confusion, postural headaches, and autonomic instability developed due to SIH, which induced profound downward displacement and compression of the diencephalon and brain stem, and accompanied by subsequent obstructive hydrocephalus. Diagnostic persistence identified the CVF, which had caused the complex multifold pathophysiology and clinical presentation. If suspicion remains high for CVF, persistent spinal imaging, particularly with dynamic myelography, may be crucial.

The algorithm for diagnosis and management of intracranial hypotension with coma: Report of two cases

Background:

Spontaneous intracranial hypotension (SIH) is caused by spontaneous cerebrospinal fluid (CSF) leaks that can be treated in most cases with an epidural blood patch (EBP). However, some patients, who develop severe brain sagging, can neurologically deteriorate, and in occasional instances, which become comatose. Here, with the presentation of two cases, and a review of the literature, we have set guidelines for diagnosing SIH along with recommendations for its management.

Case Description:

We reviewed two cases of SIH. Both patients became comatose due to a CSF leak associated with a tear in the spinal dura diagnosed on myelo-CT studies. As targeted EBP failed to achieve sustained improvement, direct operative repair of the dural tears was warranted (video presentation).

Conclusion:

After reviewing two cases of SIH and the literature, we developed an algorithm for the diagnosis and management of SIH. To avoid deterioration to a comatose status, we recommend the early performance of myelo- CT studies to identify the location of the dural leak, followed by early dural repair.

Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions

Intracranial hypotension (IH) is a relatively common condition associated with low cerebrospinal (CSF) pressure. The most typical symptom is orthostatic headache, although neurological deficits and changes in the level of consciousness, such as encephalopathy, stupor, and coma, may also occur. Uncomplicated CSF hypotension headaches generally resolve with rest, hydration, and analgesia. However, persistent cases may require an epidural blood patch (EBP) for resolution. Our report presents the case of a 50-year-old male with a history of intravenous (IV) drug abuse, positive for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) antibodies, who was admitted for new-onset headache and brain magnetic resonance imaging (MRI) findings suggesting CSF hypotension. The patient subsequently developed altered mental status with agonizing respirations, prompting intubation and admission to the intensive care unit (ICU) with neurosurgery consult. The initial exam revealed fixed and dilated pupils, suggestive of severe IH with brain herniation and the decision was made to proceed with an emergent intrathecal infusion with intraparenchymal intracranial pressure (ICP) monitoring, combined with EBP. A substantial clinical improvement was noted following the procedure. Within 45 minutes, the patient's mental status improved to normal and pupillary dilation and areflexia were no longer observed. While the procedure may need to be repeated in cases of late deterioration, this report provides evidence that intrathecal bolus saline infusion with simultaneous ICP monitoring may be considered an effective measure to treat extreme cases of IH with associated brain herniation. If performed in a timely fashion, improvement of ICP numbers, and clinical resolution can be quite rapid.

Reversible, Position-Dependent Midbrain Compression in a Patient with Spontaneous Intracranial Hypotension

BACKGROUND

Intracranial hypotension is an underrecognized cause of spontaneous subdural hematoma. Failure to identify this entity and treat the underlying etiology can result in profoundly dangerous clinical consequences, prolonged and costly hospitalization, and caregiver fatigue, as seen in the case presented here.

CASE DESCRIPTION

We present a case of intracranial hypotension associated with a spontaneous cerebrospinal fluid (CSF) leak in the cervical spine leading to consistently reproducible herniation syndrome with head of bed elevation, and bilateral subdural hematomas as a result of a pressure gradient favoring downward migration of intracranial contents resulting in traction on bridging veins. This gradient promoted transtentorial herniation with resultant brainstem compression, leading to a prolonged intensive care unit stay, recurrent respiratory failure, and severe deconditioning. An exhaustive diagnostic workup uncovered a cervical root CSF leak with a nuclear medicine CSF flow study, which was successfully treated with nerve root ligation and dural closure. The patient recovered well postprocedurally and was able to return to baseline level of function.

CONCLUSIONS

This case demonstrates the importance of considering intracranial hypotension in cases of positional herniation syndrome and the necessity for early and aggressive attempts at identifying and treating the underlying cause to prevent unnecessary neurologic dysfunction and protracted medical care.

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

BACKGROUND

Difficulties are associated with the diagnosis and management of patients with coma because of intracranial hypotension.

CASE DESCRIPTION

A 70-year-old man with coma (Glasgow Coma Scale score of 6) with fixed dilated pupils because of severe intracranial hypotension is described. After unsuccessful epidural blood patch (EBP), the patient underwent microsurgical dural repair and drainage of hematoma with intracranial pressure (ICP) monitoring. Intraoperatively, a dural tear associated with a cerebrospinal fluid (CSF) leak was identified at the thoracolumbar junction ventral to the spinal cord. The dural tear was repaired using posterior laminoplasty with a transdural approach without spinal fixation. Immediately after surgery, ICP was low, but it recovered to a physiologic range in 4 hours. Consciousness level favorably improved in a week, and the patient has remained stable for 1.5 years with good quality of life without recurrence.

CONCLUSIONS

The patient represents the first described case, to our knowledge, of intracranial hypotension with coma because of a CSF leak caused by a spinal ventral dural tear. In the setting of failed EBP attempt, our technique may be a treatment option for severe intracranial hypotension.

Treatment and outcome of subdural hematoma in patients with spontaneous intracranial hypotension: a report of 35 cases

Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, low CSF pressure and diffuse pachymeningeal enhancement on brain MRI. SIH results from spontaneous CSF leakage leading to brain sag. Sometimes, tearing of bridging veins may produce subdural hematomas (SDHs). Patients with SDH were identified retrospectively from 212 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, treatment and outcome of SDH. Thirty-five patients (16%), (6 women, 29 men; aged 33-68; mean, 50 years) with SDH were recruited. They were divided into two groups: initially withSIH diagnosed (n = 29) and undiagnosed (n = 6). After conservative treatment, the first group underwent a lumbar epidural blood patch (EBP) (n = 27) and emergent evacuation of symptomatic SDH (n = 2). After EBP, ten patients had enlarged SDH. Nine of them underwent evacuation of symptomatic SDH with mass effect (ME). In the second group, three patients with clinical worsening from SIH underwent, erroneously, evacuation of mild SDH. They worsened after the evacuation; after SIH diagnosis was made, they underwent one EBP (n = 2) and three EBPs (the patient with coma). The other three cases with symptomatic SDH with ME underwent evacuation with recurrence of SDH (n = 2). All 35 patients enjoyed a good outcome. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation. When an emergent evacuation is necessary before EBP, it is preferable to perform, after surgery, one early EBP before the patient gets up to prevent frequent recurrences of SDH by underlying CSF leakage.

The status of diagnosis and treatment to intracranial hypotension, including SIH

Intracranial hypotension, especially spontaneous intracranial hypotension (SIH), is a well-recognized entity associated with cerebrospinal fluid (CSF) leaks, and has being recognized better in resent years, while still woefully inadequate. An increasing number of factors including iatrogenic factors are realized to involve in development and progression of intracranial hypotension. The diagnosis remains difficult due to the various clinical manifestations, some of which are nonspecific and easily to be neglected. Multiple imaging tests are optional in CSF leakage identification while clinicians are still confronted with difficulties when making selection resulting from superiorities and disadvantages of different imaging tests. Treatments for intracranial hypotension are multifarious but evidence is anecdotal. Values of autologous epidural blood patching (EBP), the mainstay of first-line interventional treatment currently, is getting more and more regards while there are no systematic review of its efficacy and risks. Hereby, the purpose of this review was to reveal the present strategy of intracranial hypotension diagnosis and treatment by reviewing literatures, coupled with our experience in clinical work.

Treatment and prognosis of subdural hematoma in patients with spontaneous intracranial hypotension

Objective

The objective of this article is to elucidate the outcome, prognostic predictors and timing of surgical intervention for subdural hematoma (SDH) in patients with spontaneous intracranial hypotension (SIH).

Methods

Patients with SDH were identified retrospectively from 227 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, and treatment of SDH, which was later divided into conservative treatment, epidural blood patches (EBP), and surgical intervention. Poor outcome was defined as severe neurological sequelae or death.

Results

Forty-five patients (20%) with SDH (mean maximal thickness 11.9 ± 6.2 mm) were recruited. All 15 patients with SDH <10 mm achieved good outcomes by either conservative treatment or EBP. Of 30 patients with SDH ≥10 mm, patients with uncal herniation ( n = 3) had poor outcomes, even after emergent surgical evacuation ( n = 2), compared to those without ( n = 27) (100% vs. 0%, p < 0.001). Fourteen patients underwent surgical evacuation, resulting in good outcomes in all 12 who received early intervention and poor outcomes in the remaining two who received delayed intervention after Glasgow Coma Scale (GCS) score ≤8 (100% vs. 0%, p = 0.01).

Conclusions

Uncal herniation results in poor outcomes in patients with SIH complicated with SDH. In individuals with SDH ≥10 mm and decreased GCS scores, early surgical evacuation might prevent uncal herniation.

Spontaneous intracranial hypotension manifesting as a unilateral subdural hematoma with a marked midline shift

Spontaneous intracranial hypotension (SIH) is a syndrome in which hypovolemia of the cerebrospinal fluid (CSF) results in various symptoms. Although its prognosis is usually benign, cases with a rapid neurologic deterioration resulting in an altered mental status have been reported. One of the characteristic radiographic findings in such cases is the presence of bilateral accumulation of subdural fluid (hematoma/hygroma). When SIH-related subdural hematoma is present only unilaterally with a concomitant midline shift, making an accurate diagnosis may be challenging, and inadvertent hematoma evacuation may result in further neurologic deterioration. We report a 58-year-old woman with an altered mental status who had visited a local hospital and in whom a brain CT showed a unilateral subdural hematoma with a marked midline shift. She was referred to our department because of her neurologic deterioration after hematoma evacuation. A CT myelography revealed a massive CSF leakage in the entire thoracic epidural space. She made a full neurologic recovery following blood patch therapy. Our case is unique and educational because the suspicion for SIH as an underlying cause of subdural hematoma is warranted in nongeriatric patients not only with bilateral but also unilateral lesions. An immediate search for CSF leakage may be important in cases with failed hematoma evacuation surgery.

Low-pressure/spinal fluid leak headache

Low cerebrospinal fluid (CSF) pressure results in neurologic deficits, of which the most common manifestation is headache. Typically, the headache is postural - and specifically, orthostatic - in presentation. There are three hypotheses to explain the occurrence of headache associated with low CSF fluid. The first is traction on pain-sensitive intracranial and meningeal structures; the second is CSF hypovolemia; and the third is spinal loss of CSF resulting in increased compliance at the caudal end of the CSF space. Spontaneous intracranial hypotension (SIH), once believed to be rare, is now more commonly recognized. It is typically associated with orthostatic headache (although initially it may not be) and one or more other symptoms such as alterations in hearing, nausea, vomiting, neck stiffness, diplopia, and visual field cuts. Magnetic resonance imaging (MRI) of the brain with gadolinium is the first study of choice, which typically reveals diffuse pachymeningeal enhancement and, frequently, cerebellar tonsillar descent and posterior fossa crowding. Epidural blood patch (EBP) is the treatment of choice. Surgery and epidural fibrin glue injection are options for those who fail conservative therapy and/or EBP.

Management of postoperative pseudomeningoceles: an international survey study

BACKGROUND

Pseudomeningoceles are common complications after posterior fossa and intradural spinal surgery and are often asymptomatic. Management guidelines are lacking, and anecdotally, we have encountered radically different suggested treatments varying from observation to immediate surgical intervention. The goal of this study was to determine the prevailing opinions among neurosurgeons on the management of this condition.

METHODS

Neurosurgeons from around the world were invited via an International Society for Pediatric Neurosurgery (ISPN) and Neurosurgery ListServ e-blast to participate in a 33-question survey on the management of pseudomeningoceles, presented as simulated scenarios after posterior fossa and spinal intradural surgery.

RESULTS

Two hundred forty-one responses were obtained. Pseudomeningoceles after posterior fossa tumor resection, in the absence of hydrocephalus, were typically managed nonoperatively for 7 to 14 days before re-exploration. Only 0.5 % of the surgeons would offer upfront repair of the pseudomeningocele. In the presence of hydrocephalus, 48 % of the neurosurgeons intervene initially with cerebrospinal fluid (CSF) diversion and would change therapy if the lesion did not resolve in 2 to 4 days. Ninety percent of the surgeons manage spinal pseudomeningoceles nonoperatively for 7-14 days before re-exploration is considered. The most common steps taken to prevent pseudomeningoceles are watertight closure, tissue glues, and duroplasty.

CONCLUSION

The present zeitgeist suggests that, in the absence of hydrocephalus, initial observation is appropriate for cranial and spinal pseudomeningoceles. Operative revision should be reserved for failure of conservative treatment. If hydrocephalus is present, consideration should be made for CSF diversion. This study may serve as a guideline regarding acceptable management.