Disturbed Consciousness and Coma: Diagnosis and Management of Intracranial Hypotension Caused by a Spinal Cerebrospinal Fluid Leak

Takai, Keisuke; Niimura, Manabu; Hongo, Hiroki; Umekawa, Motoyuki; Teranishi, Akio; Kayahara, Tomomichi; Taniguchi, Makoto

doi:10.1016/j.wneu.2018.09.193

Cited by 19 publications

(6 citation statements)

References 28 publications

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“…In the case series described by Hadizadeh et al, 4 PIHV patients with severe thalamic or basal ganglia signal intensity changes on computed tomography and MRI indicated poor prognosis with significantly worse modified Rankin Scale and Glasgow Outcome Scale scores at 3-mo postinjury when compared with PIHV patients who did not have these imaging signal changes 4 . Prompt recognition of PIHV and early neurosurgical intervention with duraplasty or epidural blood patch can result in clinical improvement in some cases, but multiple cases have reported disability or death despite surgical intervention 2,4,6–8 . Currently, there are no nonsurgical strategies reported to reverse neurologic injury due to PIHV.…”

Section: Impact To Clinical Practicementioning

confidence: 99%

“…4 Prompt recognition of PIHV and early neurosurgical intervention with duraplasty or epidural blood patch can result in clinical improvement in some cases, but multiple cases have reported disability or death despite surgical intervention. 2,4,[6][7][8] Currently, there are no nonsurgical strategies reported to reverse neurologic injury due to PIHV.…”

Section: Impact To Clinical Practicementioning

confidence: 99%

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Postoperative Treatment of Intracranial Hypotension Venous Congestion–Associated Brain Injury With Zolpidem

Milleville

Wagner

2020

Am J Phys Med Rehabil

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A previously independent 75-yr-old man developed postoperative intracranial hypotension–associated venous congestion after an elective T10-pelvis fusion, which was complicated by durotomy. Postoperative day 0 magnetic resonance imaging noted symmetric edema of the basal ganglia, thalami, and cerebellar cortex as well as smooth diffuse pachymeningeal enhancement and dural thickening, consistent with postoperative intracranial hypotension–associated venous congestion. On postoperative day 0, patient developed tonic clonic seizures, and on postoperative day 2, patient was unable to follow commands or blink to visual threat, able to track eyes to sound only, and spontaneously moved all limbs. Patient was started on zolpidem 2.5 mg on postoperative day 2, and 12 hrs later, he had significantly improved motor function, arousal, verbalization, and followed simple commands. After three doses, patient was fully alert and oriented with improved mobility and comprehension. Six zolpidem doses were administered in total, and repeat magnetic resonance imaging on postoperative day 16 showed markedly improved regional edema. The patient was admitted to a brain injury inpatient rehabilitation unit and was discharged to home 9 days later with Functional Independence Measure gain of 17. Intracranial hypotension can adversely affect primary mesocircuit structures supporting arousal. Zolpidem, a selective α-1-subunit GABA-A agonist, supports GABAergic tone in these regions. This patient’s clinical presentation and recovery paralleled selective basal ganglial-thalamic edema development and resolution.

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Section: Impact To Clinical Practicementioning

confidence: 99%

Section: Impact To Clinical Practicementioning

confidence: 99%

Postoperative Treatment of Intracranial Hypotension Venous Congestion–Associated Brain Injury With Zolpidem

Milleville

Wagner

2020

Am J Phys Med Rehabil

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“…Spontaneous intracranial hypotension (SIH) is frequently complicated by subacute subdural hematoma (SDH) (1)(2)(3)(4) and more rarely bilateral thalamic ischemia (5)(6)(7)(8). The management of this condition is poorly codified and is often based on surgical evacuation of the SDH.…”

Section: Introductionmentioning

confidence: 99%

“…However, this therapeutic approach remains controversial because of the paradoxical nature of removing the intracranial volume in the context of pre-existing hypotension. Consequently, a growing number of authors now recommend treating SIH-related SDH with a blood patch, targeted to a possible dural tear or not (1,4,(8)(9)(10)(11)(12). The management of rare bilateral thalamic strokes is even less known.…”

Section: Introductionmentioning

confidence: 99%

Case report: Simultaneous measurement of intracranial pressure and lumbar intrathecal pressure during epidural patch therapy for treating spontaneous intracranial hypotension syndrome. Spontaneous intracranial hypotension or spontaneous intraspinal hypovolume?

Engrand,

Salardaine,

Desilles

et al. 2024

Front. Neurol.

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ObjectivesSpontaneous intracranial hypotension (SIH) is frequently complicated by subacute subdural hematoma (SDH) and more rarely by bilateral thalamic ischemia. Here, we report a case of SIH-related SDH treated with three epidural patches (EPs), with follow-up of the intracranial pressure and lumbar intrathecal pressure.MethodsA 46-year-old man presented bilateral thalamic ischemia, then a growing SDH. After failure of urgent surgical evacuation, he underwent three saline EPs, two dynamic myelography examinations and one digital subtraction angiography–phlebography examination. However, because of no dural tear and no obstacle to the venous drainage of the vein of Galen, no therapeutic procedure was available, and the patient died.ResultsThe case exhibited a progressive increase in the transmission of lumbar intrathecal pressure to intracranial pressure during the three EPs. The EPs may have successfully treated the SIH, but the patient did not recover consciousness because of irreversible damage to both thalami.ConclusionClinicians should be aware of the bilateral thalamic ischemia picture that may be the presenting sign of SIH. Moreover, the key problem in the pathophysiology of SIH seems to be intraspinal and intracranial volumes rather than pressures. Therefore, intracranial hypotension syndrome might actually be an intraspinal hypovolume syndrome.

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“…Die Erkrankung wird im Allgemeinen nicht als lebensbedrohlich eingestuft, dennoch können damit ernste Langzeitfolgen und in einzelnen Fällen Bewusstseinsstörungen bis hin zum Koma verbunden sein [1,2,3,4].…”

Section: Introductionunclassified

Spontane intrakranielle Hypotension

Albes

2023

Neurologie up2date

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Disturbed Consciousness and Coma: Diagnosis and Management of Intracranial Hypotension Caused by a Spinal Cerebrospinal Fluid Leak

Cited by 19 publications

References 28 publications

Postoperative Treatment of Intracranial Hypotension Venous Congestion–Associated Brain Injury With Zolpidem

Postoperative Treatment of Intracranial Hypotension Venous Congestion–Associated Brain Injury With Zolpidem

Case report: Simultaneous measurement of intracranial pressure and lumbar intrathecal pressure during epidural patch therapy for treating spontaneous intracranial hypotension syndrome. Spontaneous intracranial hypotension or spontaneous intraspinal hypovolume?

Spontane intrakranielle Hypotension

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