When does too little pressure become too much? A case of spontaneous intracranial hypotension presenting with acute loss of consciousness

Abstract

Background: We present a unique case of spontaneous intracranial hypotension (SIH) presenting with acute collapse and loss of consciousness.

Case description: The affected patient suffered an abrupt decline in level of consciousness several weeks after initial diagnosis. The patient was urgently transferred to a specialist neurosurgical unit. Imaging showed bilateral subdural fluid collections with significant associated local mass effect. The treating team faced a clinical conundrum with a lack of clarity as to whether this sudden deterioration was secondary to the local pressure effect on brainstem traction from reduced intracranial pressure. A decision was made to proceed with urgent burr-hole decompression of the bilateral subdural fluid collections.

Conclusion: After a protracted, complex postoperative course, the patient recovered to full functional independence. To the author's knowledge, this is the first case in literature describing successful surgical management of SIH, with bilateral burr-hole evacuation to relieve the paradoxical mass effect of bilateral subdural fluid collections.

Keywords: Cerebrospinal fluid effusion; Essential intracranial hypotension; Neurosurgery; Spontaneous subdural surgical management.

Figure 1:

Bifrontal hypoattenuating subdural collections on axial noncontrast computed tomography (CT) brain.

Figure 2:

(a) High-signal fluid collections on axial T2-weighted magnetic resonance imaging (MRI) brain. (b) Diffuse pachymeningeal enhancement on axial T1 post contrast MRI brain, indicative of intracranial hypotension.

Figure 3:

Sagittal T2-weighted magnetic resonance spine demonstrating anterior and posterior epidural fluid collections (red arrows) in the cervicothoracic region.

Figure 4:

Repeat computed tomography (CT) brain with increasing size of right-sided subdural collection.

Figure 5:

Magnetic resonance imaging brain (MRI) demonstrating (a) focal area of hyperintensity in the left pons on axial fluid attenuated inversion recovery and (b) corresponding diffusion restriction on diffusion-weighted imaging.

Figure 6:

Serial magnetic resonance imaging spines demonstrating steadily reducing epidural fluid collections (red arrows) on (a) day 1 postoperative (b) day 1 post first blood patch, and (c) day 1 post repeat blood patch.