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Case Reports
. 2023 Apr 10:10:93-98.
doi: 10.2176/jns-nmc.2022-0356. eCollection 2023.

Two Cases of Chronic Subdural Hematoma with Spontaneous Intracranial Hypotention Treated with Hematoma Drainage Followed by Epidural Blood Patch Under Intracranial Pressure Monitoring

Toshitsugu Terakado  1 , Akibumi Omi  2 , Yuji Matsumaru  3 , Eiichi Ishikawa  3
Affiliations
Case Reports

Two Cases of Chronic Subdural Hematoma with Spontaneous Intracranial Hypotention Treated with Hematoma Drainage Followed by Epidural Blood Patch Under Intracranial Pressure Monitoring

Toshitsugu Terakado et al. NMC Case Rep J. .

Abstract

Both chronic subdural hematoma (CSDH) and spontaneous intracranial hypotension (SIH) cause headaches. However, the etiologies are different: SIH headache is caused by decreased intracranial pressure (ICP), whereas CSDH headache results from increased ICP. Moreover, CSDH is treated by hematoma drainage, while SIH is treated by epidural blood patch (EBP). Treatment for the cases of combined SIH and CSDH is not well-established. Herein, we report two cases wherein ICP was monitored and safely controlled by EBP after hematoma drainage. Case 1: A 55-year-old man with progressive consciousness disturbance was diagnosed with bilateral CSDH. He underwent bilateral hematoma drainage; however, the headache became apparent during standing. We diagnosed SIH by diffuse pachymeningeal enhancement on brain MRI and epidural contrast medium leakage on CT myelography. Due to the re-enlargement of bilateral CSDH, we performed EBP after hematoma drainage and ICP monitor insertion. Finally, the headache and bilateral CSDH were resolved. Case 2: A 54-year-old man with persistent headache was diagnosed with bilateral CSDH. He underwent multiple hematoma drainage sessions. However, headache on standing persisted. We diagnosed SIH by diffuse pachymeningeal enhancement on brain MRI and epidural contrast medium leakage on CT myelography. Due to the re-enlargement of the left CSDH, we performed EBP after left hematoma drainage and ICP monitor insertion. Finally, the headache and bilateral CSDH were resolved. EBP after hematoma drainage and ICP monitoring was useful for SIH with bilateral CSDH. By monitoring ICP before EBP, the ICP was safely controlled and CSDH was resolved.

Keywords: chronic subdural hematoma; epidural blood patch; intracranial pressure monitoring; spontaneous intracranial hypotension.

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Conflict of interest statement

The authors have no conflicts of interest and have registered online self-reported COI disclosure statement forms through the website for The Japan Neuro-surgical Society members.

Figures

Fig. 1
Fig. 1
A, B: Initial brain CT scan shows bilateral CSDH and pseudo-SAH. C: Brain MRI shows diffuse pachymeningeal enhancement. D, E: CT myelography reveals epidural contrast retention at the C6-T2 level.
Fig. 2
Fig. 2
A: Postoperative CT scan shows epidural contrast retention. B, C: Brain CT scan 3 months after operation shows CSDH disappearance. D: Time course of case 1.
Fig. 3
Fig. 3
A, B: Initial brain CT scan shows bilateral CSDH and pseudo-SAH. C: Brain MRI shows diffuse pachymeningeal enhancement. D, E: CT myelography reveals epidural contrast retention at the Th2-Th8 level.
Fig. 4
Fig. 4
A: Postoperative CT scan shows epidural contrast retention. B, C: Brain CT scan 3 months after operation shows CSDH disappearance. D: Time course of case 2.
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