Spontaneous intracranial hypotension associated with cerebral venous thrombosis detected by a sudden seizure: a case report

Prevalence, clinical presentation, and treatment-management of cerebral venous thrombosis associated with spontaneous intracranial hypotension: A combined case-series and systematic literature review approach

BACKGROUND

Cerebral venous thrombosis (CVT) is a rare complication of spontaneous intracranial hypotension (SIH). Therefore, its correct diagnosis and the corresponding optimal treatment-management identification remains challenging.

METHODS

Over the last 10 years, 300 patients received a definite SIH diagnosis at our stroke center. Through thorough review of the database, we identified all patients with SIH-related CVT. In addition, we performed a systematic literature review including all publications on SIH-related CVT.

RESULTS

Five out of our 300 SIH patients showed CVT (F/M:2/3, mean age: 51.8 ± 15.7). Through the literature search, 72 additional cases were identified. Overall, the prevalence was 1.3% and main clinical presentations were orthostatic headache, nausea, and vomiting. The CVT was predominantly located at the superior sagittal sinus. Treatment strategies included anticoagulants (ACs) (43%), epidural blood patch (EBP) (19.4%), and combined AC + EBP (33.3%). In our cohort, all but one patient received combined EBP and AC. The mean clinical and radiological follow-up were 2 years and 1.5 years, respectively. Complete clinical recovery was reported in 96% of the cases, whereas 56% showed complete radiological CVT resolution. Among patients without radiological resolution (26.4%), 57% received AC-only, while 43% received combined AC + EBP. Of our five cases, all but one patient received combined AC + EBP.

CONCLUSION

The overall prevalence of SIH-related CVT was 1.3%. AC and combined AC + EBP were the most used treatment-management strategies. CVT resolution was more commonly achieved after the combined strategy. Overall, the rate of complete clinical recovery was 96%.

Spontaneous Intracranial Hypotension Discovered Following Cerebral Venous Thrombosis: A Case Report and Review of the Literature

Cerebral venous thrombosis (CVT) is a rare complication of spontaneous intracranial hypotension (SIH). We encountered a case where SIH was discovered after the diagnosis of CVT, suggesting the occurrence of CVT during the acute phase of SIH. We report this rare case of isolated cortical vein thrombosis in the acute phase of SIH. A 48-year-old woman taking low-dose oral contraceptives presented with neck pain, headache, and right-sided weakness. Magnetic resonance imaging and digital subtraction angiography confirmed isolated cortical vein thrombosis. No other specific imaging abnormalities were noted. The patient was initially treated with anticoagulation. Subsequent worsening of her orthostatic headache led to the diagnosis of SIH, with diffuse dural enhancement on gadolinium-enhanced T1-weighted imaging. An epidural blood patch was performed, resulting in a favorable outcome with no neurological deficits. Although CVT can occur in the acute phase of SIH, particularly in patients with thrombophilia, the lack of characteristic imaging findings associated with SIH often complicates the diagnosis.

Superior Sagittal Sinus Thrombosis in a Patient With Iatrogenic Intracranial Hypotension: A Case Report

Cerebral venous thrombosis is a rarely reported complication of iatrogenic intracranial hypotension. We discuss a rare case of a 46-year-old woman presenting with a week-long history of severe orthostatic headaches two weeks following L4-L5 microscopic discectomy for symptomatic lumbar disc herniation. Computed tomography venography of the head revealed evidence of superior sagittal sinus thrombosis while contrast-enhanced magnetic resonance imaging of the brain revealed signs of intracranial hypotension consisting of pachymeningeal enhancement, bilateral subdural hygromas, enlarged pituitary gland, effacement of the basal ambient cisterns, and low-lying cerebellar tonsils. Additional lumbar spine imaging revealed the culprit to be a large epidural fluid collection extending from the epidural space to the superficial subcutaneous fat, suggestive of a cerebrospinal fluid leak. The patient was managed with admission, bed rest, isotonic intravenous fluids, caffeine, and therapeutic dosing of low molecular weight heparin. In such cases, clinical suspicion and early recognition and management are of paramount importance to prevent devastating consequences. Management, whether conservatively or with surgical intervention, should be made on a case-by-case basis.

Thunderclap headache revealing dural tears with symptomatic intracranial hypotension: Report of two cases

Cerebrospinal fluid (CSF) leakage is considered the cause of spontaneous intracranial hypotension (SIH), an important etiology for new daily persistent headaches and a potentially life-threatening condition. Minor traumatic events rarely lead to CSF leakage, contrasting with iatrogenic interventions such as a lumbar puncture or spinal surgery, which are commonly complicated by dural tears. Most meningeal lesions are found in the cervicothoracic region, followed by the thoracic region, and rarely in the lumbar region, and extremely rarely in the sacral region. We describe two patients admitted to our hospital for severe headaches aggravated in the orthostatic position, with a recent history of minor trauma and sustained physical effort, respectively. In the first case, a bone fragment pierced an incidental congenital meningocele creating a dural fistula. An extensive extradural CSF collection, spanning the cervicothoracic region (C4-T10), was described in the second case. In both patients, the clinical evolution was favorable under conservative treatment.

Cerebral venous thrombosis following spontaneous intracranial hypotension diagnosed by craniotomy: A case report and diagnostic pitfalls

Background:

Cerebral vein and dural sinus thrombosis (CVT) is a rare but important complication of spontaneous intracranial hypotension (SIH). The diagnosis is difficult in cases lacking typical symptoms and typical imaging findings.

Case Description:

A 29-year-old male patient with a seizure attack was admitted to our hospital. Based on the head imaging findings, we misdiagnosed the patient with primary cerebral parenchymal lesion and performed an open biopsy. However, during the procedure, the patient was diagnosed with low cerebrospinal fluid pressure and cerebral cortical vein thrombosis.

Conclusion:

Thus, CVT due to SIH should be considered as a probable cause of secondary parenchymal lesions.

Cerebral venous thrombosis in spontaneous intracranial hypotension: A report of 8 cases and review of the literature

BACKGROUND

The occurrence of cerebral venous thrombosis (CVT) in patients with spontaneous intracranial hypotension (SIH) raises difficult practical questions regarding the management of the two conditions. The first-line therapy for CVT is anticoagulation (AC); however, its potential benefit in SIH/CVT patients, especially if complicated by subdural haematoma, must be carefully evaluated taking account of the intracranial haemorrhage risk. Venous system recanalization and good prognosis in SIH/CVT patients treated with epidural blood patch (EBP), the main treatment option for SIH, have been already described.

METHODS

We reviewed our cases of SIH complicated by CVT among a cohort of 445 SIH patients observed and treated during the last years. All published case reports and case series reporting patients with SIH and CVT were also ascertained and reviewed.

RESULTS

Eight (2%) out of 445 patients suffering with SIH, were also diagnosed with CVT. All patients observed had orthostatic headache, three of them experienced a change in their headache pattern over the SIH course. Six out of eight patients received both AC and EBP treatments. Two patients were treated using only AC or EBP. A bilateral subdural haematoma enlargement after 1 month of AC was observed in one case. Complete CVT recanalization after treatment was obtained in three patients, including two with multiple CVT at baseline; partial CVT recanalization was achieved in two patients. Three patients experienced no CVT recanalization. After 6-48 months' follow-up all patients were still asymptomatic.

CONCLUSIONS

The use of AC therapy should be weighed against the intracranial haemorrage risk and should be monitored carefully if initiated. Effective and prompt EBP, even without AC therapy, might lead to a good prognosis in selected cases.