A Severe Case of Spontaneous Intracranial Hypotension in an Adult Asian Male Improved With Trendelenburg Positioning: A Case Report

Abstract

Non-traumatic bilateral acute subdural hematomas are a rare occurrence. Etiologies typically include, but are not limited to, cortical artery bleeding, vascular lesions, coagulopathies, and spontaneous intracranial hypotension. We report a case of a 45-year-old Korean male with no known co-morbid illnesses nor history of head or neck trauma, who came to the emergency department due to a 10-day history of dizziness and head heaviness, followed by disorientation and drowsiness. The patient was diagnosed with bilateral acute subdural hematoma; hence, a bilateral posterior parietal craniotomy with evacuation of hematoma was performed. Neurologic status initially improved remarkably; however, during rehabilitation, there was recurrence of acute bilateral subdural hematoma requiring repeat surgical evacuation. There was no clinical improvement after the repeat surgery, and his condition further deteriorated in the neurosciences critical care unit showing signs of rostrocaudal deterioration at the level of diencephalon. A plain cranial CT scan was performed, which showed central herniation and "brain sagging." A diagnosis of spontaneous intracranial hypotension was considered; thus, the patient was managed by positioning him in the Trendelenburg position alternating with flat position on the bed. A search for the cerebrospinal fluid leak was commenced by performing a whole spine MRI constructive interference in steady state (CISS) protocol, which showed a longitudinal spinal anterior epidural cerebrospinal fluid leak from spinal level C2 to T1. Radionuclide cisternography did not provide definitive scintigraphic evidence of a leak. The patient gradually improved and was eventually transferred out of the neurosciences critical care unit. After days of rehabilitation in the hospital, the patient was discharged ambulatory with minimal support.

Keywords: bilateral subdural hematoma; brain herniation; spontaneous cerebrospinal fluid leak; spontaneous intracranial hypotension; trendelenburg.

Figure 1. Non-contrast cranial MRI in (A) T1 and (B) T2 axial views showing a hyperacute to acute subdural hemorrhage along both cerebral convexities.

Figure 2. Plain cranial CT scan in (A) coronal and (B) axial views showing recurrence of subdural hematoma with leftward midline shift.

Figure 3. Non-contrast cranial MRI in (A) axial T2 and (B) sagittal T2 sequences showing compression of the bilateral midbrain and obliteration of the perimesencephalic sulcus.

Figure 4. Cervical MRI CISS protocol in (A) T2 and (B) contrast sagittal views showing a longitudinal CSF collection in the anterior extradural space from the level of C2 down to the level of T1, effacing the thecal sac. (C) Radionuclide cisternography showing no diffusion of radioisotope in the extra-arachnoidal space.

CISS, constructive interference in steady state; CSF, cerebrospinal fluid