Intracranial hypotension

Hydrocephalus and intracranial hypotension

Authors: Reith W, Yilmaz U. (Article in German)

Ventricular enlargement due to a imbalance of the production of cerebrospinal fluid and its absorption can be a symptom of a variety of diseases. The causes are increased production or decreased absorption of cerebrospinal fluid and obstructions to cerebrospinal fluid flow. Treatment requires thorough neuroradiological imaging with high-resolution thin-section magnetic resonance imaging (MRI) and cerebrospinal fluid flow measurements. Thus, for instance even small membranes causing aqueductal obstruction can be detected and their influence on cerebrospinal fluid flow can be analyzed. The results of neurosurgical therapy, such as ventriculostomy can also be evaluated. This article provides an overview about imaging features as well as clinical and therapeutic aspects of hydrocephalus.

Postpartum Trifecta: Simultaneous Eclamptic Intracerebral Hemorrhage, PRES, and Herniation Due to Intracranial Hypotension

Authors: Orehek EK, Burns JD, Koyfman F, Azocar RJ, Holsapple JW, Green DM.

BACKGROUND: In the postpartum patient, sudden depression of consciousness may be caused by a number of etiologies and can result in serious consequences. Rapid, accurate diagnosis allows for specific treatments that optimize outcome, but diagnosis can be challenging in this population. We present a case of postpartum herniation due to intracranial hypotension in a patient with eclampsia, posterior reversible encephalopathy syndrome (PRES), and intracerebral hemorrhage (ICH).

Headache Due to Spontaneous Intracranial Hypotension and Subsequent Cerebral Vein Thrombosis

Authors: Costa P, Del Zotto E, Giossi A, Volonghi I, Poli L, Frigerio M, Padovani A, Pezzini A.

Cerebral vein thrombosis (CVT) is a rare complication of spontaneous intracranial hypotension (SIH). When to suspect a thrombotic disorder during the course of intracranial hypotension is not fully elucidated. A 48-year-old woman was admitted because of SIH with no signs of CVT on neuroimaging. The occurrence of diplopia and blurred vision 12 days later led to the performance of further investigations, which revealed thrombosis of the left lateral sinus, in the absence of variations in the headache characteristics. Among the other 4 cases of SIH clearly preceding the occurrence of CVT reported so far, only one had a change in the headache pattern related to CVT development. Although a change in the characteristics of headache is considered a marker of CVT in patients with SIH, this is not invariably part of the clinical scenario. Any new neurologic finding on exam in the disease course should raise a suspicion of venous thrombosis, thus prompting further specific investigations.
© 2012 American Headache Society.

Intracranial hypotension producing reversible coma: a systematic review, including three new cases

Authors: Loya JJ, Mindea SA, Yu H, Venkatasubramanian C, Chang SD, Burns TC.

Intracranial hypotension is a disorder of CSF hypovolemia due to iatrogenic or spontaneous spinal CSF leakage. Rarely, positional headaches may progress to coma, with frequent misdiagnosis. The authors review reported cases of verified intracranial hypotension-associated coma, including 3 previously unpublished cases, totaling 29. Most patients presented with headache prior to neurological deterioration, with positional symptoms elicited in almost half. Eight patients had recently undergone a spinal procedure such as lumbar drainage. Diagnostic workup almost always began with a head CT scan. Subdural collections were present in 86%; however, intracranial hypotension was frequently unrecognized as the underlying cause. Twelve patients underwent one or more procedures to evacuate the collections, sometimes with transiently improved mental status. However, no patient experienced lasting neurological improvement after subdural fluid evacuation alone, and some deteriorated further. Intracranial hypotension was diagnosed in most patients via MRI studies, which were often obtained due to failure to improve after subdural hematoma (SDH) evacuation. Once the diagnosis of intracranial hypotension was made, placement of epidural blood patches was curative in 85% of patients. Twenty-seven patients (93%) experienced favorable outcomes after diagnosis and treatment; 1 patient died, and 1 patient had a morbid outcome secondary to duret hemorrhages. The literature review revealed that numerous additional patients with clinical histories consistent with intracranial hypotension but no radiological confirmation developed SDH following a spinal procedure. Several such patients experienced poor outcomes, and there were multiple deaths. To facilitate recognition of this treatable but potentially life-threatening condition, the authors propose criteria that should prompt intracranial hypotension workup in the comatose patient and present a stepwise management algorithm to guide the appropriate diagnosis and treatment of these patients.

Spontaneous low pressure headache - A review and illustrative patient

Authors: Lahoria R, Allport L, Glenn D, Masters L, Shnier R, Davies M, Hersch M.

Low pressure headache typically occurs as a complication of dural puncture. "Spontaneous" low pressure headache is a relatively rare but under-recognised cause of intractable headache. Clinical suspicion of this condition warrants imaging of the brain to confirm the diagnosis; spinal imaging may be needed to identify the site of the leak. Epidural blood patching may be necessary to seal the leak - CT fluoroscopy may be helpful in delivering the patch directly to the site of the leak. Surgical intervention may be required in intractable cases. We describe a patient with spontaneous intracranial hypotension and review the clinical and radiological features of this syndrome.

Spontaneous intracranial hypotension: A case study

Authors: Tyree TL, Porter R.

Purpose: To present an illustrative case study of a patient with spontaneous intracranial hypotension (SIH) and to increase awareness of this condition among nurse practitioners (NPs). Data sources: A literature search was conducted, and deidentified patient information forms the basis of this presentation. The authors' experience and appropriate images enhance the presentation of the case study. Conclusions: SIH is a condition that typically occurs without a traumatic event, although it can be associated with minor trauma. It occurs when cerebrospinal fluid (CSF) leaks through a focal weakness in the dural sac or meningeal diverticula, resulting in CSF hypovolemia. Patients usually present with an orthostatic headache. The most common brain magnetic resonance imaging findings are diffuse pachymeningeal enhancement, descent of the cerebellar tonsils, and subdural fluid collections. Treatment options range from management of symptoms to surgical repair of the leak. Implications for practice: As NPs continue to provide care in a variety of settings, including emergency departments and urgent care areas, they must be familiar with the progression of symptoms that might indicate SIH and be prepared to make appropriate referrals to prevent iatrogenic morbidity.
©2012 The Author(s) Journal compilation ©2012 American Academy of Nurse Practitioners.

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