J Korean Neurotraumatol Soc.  2011 Oct;7(2):103-107. 10.13004/jknts.2011.7.2.103.

Two Cases of Secondary Intracranial Hypotension

• Kim YS
• Cho BM
• Cho SM
• Park SH
• Oh SM

• KMID: 2019923
• DOI: http://doi.org/10.13004/jknts.2011.7.2.103

Abstract

Intracranial hypotension (IH) is a clinical syndrome which leads to orthostatic headache due to low cerebrospinal fluid (CSF) volume. Severe cases are present with nausea, vomiting, photophobia, and rarely, decreased level of consciousness and coma. The various modalities for diagnosing CSF leakage have been used, such as radionuclide cisternography (RNC), CT myelography and MRI myelography. Despites of the various modalities, the actual location of leakage is hard to find. We present two patients who underwent RNC for suspected CSF leakage after trauma and lumbar puncture. One case, site of CSF leakage was misidentified. The other case, we performed burr hole trephination with closed drainage due to progressive subdural hematoma (SDH) after epidural blood patch (EBP). This report emphasizes that intracranial hypotension presents with various clinical presentation and neuroimaging findings.

Keyword

Intracranial hypotension; Radionuclide cisternography; Cerebrospinal fluid leak

MeSH Terms

Blood Patch, Epidural
Cerebrospinal Fluid Rhinorrhea
Coma
Consciousness
Drainage
Headache
Hematoma, Subdural
Humans
Intracranial Hypotension
Myelography
Nausea
Neuroimaging
Photophobia
Spinal Puncture
Vomiting
Cerebrospinal Fluid Rhinorrhea

Figure

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  FIGURE 1 Case 1. Follow up computed tomography demonstrates widening of bilateral frontal and temporal subdural space (A). Gadolinium-enhanced brain magnetic resonance imaging shows bilateral frontal and temporal subdural space widening and diffuse pachymeningeal enhancement (B, C, D).

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  FIGURE 2 Case 1. Radionuclide cisternography shows mild reflux of radiotracer into the lateral ventricle (A). Supine spinal images demonstrate no evidence of a CSF leakage (B). The radiotracer accumulation activity at the left cerebellopontine angle (CPA) cistern was seen, but that was decreased on the 24-hour delayed images (A,C). T2-weighted MRI shows asymmetry of CPA cistern (D). CSF: cerebrospinal fluid.

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  FIGURE 3 Case 2. Initial brain CT shows acute subdural hematoma on left cerebral hemisphere (A). T1-weighted MRI shows acute subdural hematoma on left cerebral hemisphere with midline shifting to right and diffuse pachymeningeal enhancement (B, C). CT: computed tomography.

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  FIGURE 4 Case 2. Radionuclide cisternography shows multiple CSF leakage at right anterolateral aspect and left posterolateral aspect of lower lumbar (A, B, C). CSF: cerebrospinal fluid.

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  FIGURE 5 Case 2. Pre-operative contrast enhanced CT at 2 weeks after EBP shows slightly increased volume of SDH with aggravation of midline shifting to the right (A), post-operative CT after burr hole trephination with closed drainage (B). CT: computed tomography, EBP: epidural blood patch, SDH: subdural hematoma.

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