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Abstract
INTRODUCTION
Spontaneous intracranial hypotension (SIH) is an uncommon and generally self-limiting condition caused by low cerebrospinal fluid (CSF) volume usually secondary to a CSF-leak. This process results in a downward traction of the brain, causing headaches, subdural fluid collections and possible brain herniation. 16–57% of patients are expected to suffer from subdural hematomas (SDH). SIH treatment prior or after SDH management still remains controversial.
METHODS
Procedure/Clinical findings A 48-year-old man presented with an orthostatic headache of 3-months duration that worsened for the last few hours. A CT-scan showed SDH. A bilateral craniotomy with drain placement was performed. The drain was removed 24 hours later at a bedside procedure, triggering headache, tonic posture, right ocular deviation and altered mental status. A new CT-scan showed SDH recurrence. After a second intervention, SIH was diagnosed. An epidural blood patch (EBP) was performed. With no change in the clinical outcome, SDH recurred and a third intervention with drain placement was performed. In the post-op period, normal sterile saline was infused into the subdural space at the same time the drain was being removed.
RESULTS
The patient was discharged with no recurrence of neurologic signs after a 24-month follow-up. It is hypothesized that drain removal causes a direct communication between the atmosphere and intrathecal space, further decreasing the intracranial pressure in SIH patients. These would cause either brain herniation or recurrence of SDH. To avoid a sudden decrease of intracranial pressure and mask the effect of atmospheric pressure, we infused saline solution into the subdural space simultaneous to drain retraction.
CONCLUSION
SIH is a frequently misdiagnosed disorder. No standardized treatment has been established for SDH/SIH presentation as some centers perform EBP either before or after hematoma evacuation. To our knowledge, this is the first report of clinical resolution with transoperative subdural saline infusion. Further consensus needs to be reached as the prognosis of SDH/SIH can be largely impacted by an approach proven to be safe and free of long-term complications.