Sagging brain causing postural loss of consciousness: a case of severe spontaneous intracranial hypotension

Lagrand, Tjerk J; Beukers, Richard

doi:10.1136/practneurol-2015-001183

Cited by 5 publications

(12 citation statements)

References 21 publications

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“…In keeping with the case Lagrand [44] reported, very few patients characterized by alterations in conscious levels leading to coma or even death, which caused by severe sagging brain, subdural hematoma or venous sinus thrombosis. In emergency, adequate amount of intrathecal saline infusion can be a useful temporizing measure to normalize the intracranial pressure and so gain time to investigate and correct the CSF leak [89], as Stephen described in an instructive case report [90].…”

Section: Reviewsupporting

confidence: 84%

“…It might be gradual or thunderclap in onset [8, 39], less or more positional over time, even intermittent [40], no relationship with position [41] or become worse when lying down [42], and the intensity of headache was variable [12] or absence of headache [12, 43]. Lagrand [44] reported a severe SIH case of orthostatic unconsciousness might caused by diencephalic herniation [45, 46]. Other cardinal symptoms reported are nausea and vomiting occurred in about half of patients [8, 47], always accompanied by neck pain stiffness [26], blurred vision [12], “visual” filed defects and diplopia [48], cough headache [30], facial pain or numbness [49], tinnitus [41], taste alternations [8, 47] and limb paresthesias [50] and transient third cranial nerve palsy [51].…”

Section: Reviewmentioning

confidence: 99%

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The status of diagnosis and treatment to intracranial hypotension, including SIH

Lin

Zhang

et al. 2017

J Headache Pain

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Intracranial hypotension, especially spontaneous intracranial hypotension (SIH), is a well—recognized entity associated with cerebrospinal fluid (CSF) leaks, and has being recognized better in resent years, while still woefully inadequate. An increasing number of factors including iatrogenic factors are realized to involve in development and progression of intracranial hypotension. The diagnosis remains difficult due to the various clinical manifestations, some of which are nonspecific and easily to be neglected. Multiple imaging tests are optional in CSF leakage identification while clinicians are still confronted with difficulties when making selection resulting from superiorities and disadvantages of different imaging tests. Treatments for intracranial hypotension are multifarious but evidence is anecdotal. Values of autologous epidural blood patching (EBP), the mainstay of first-line interventional treatment currently, is getting more and more regards while there are no systematic review of its efficacy and risks. Hereby, the purpose of this review was to reveal the present strategy of intracranial hypotension diagnosis and treatment by reviewing literatures, coupled with our experience in clinical work.

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Section: Reviewsupporting

confidence: 84%

Section: Reviewmentioning

confidence: 99%

The status of diagnosis and treatment to intracranial hypotension, including SIH

Lin

Zhang

et al. 2017

J Headache Pain

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“…Since CSF provides protective buoyancy to intracranial structures, a leak can cause the brain to descend and increased traction of pain-sensitive structures. Patients may present with postural occipital headache, nausea, vomiting, radiculopathy, tinnitus, vertigo, nuchal rigidity, photophobia and cranial nerve palsies [2,4-6]. Recognition of a prominent inferior intercavernous sinus may assist in diagnosing SIH, which presents as a rounded structure at the floor of the sellae seen in 50% of patients with SIH [6].…”

Section: Discussionmentioning

confidence: 99%

“…Recent neuroimaging studies have shown CSF leakage to be the probable etiology [2]. Diagnosis of SIH is supported by magnetic resonance imaging (MRI), indicating the displacement of the brainstem and causing occipital headache and meningism.…”

Section: Introductionmentioning

confidence: 99%

Spontaneous Intracranial Hypotension Presenting as a "Pseudo-Chiari 1"

Haider

Sulhan

Watson

et al. 2017

Cureus

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Spontaneous intracranial hypotension (SIH) is classified as a decrease in cerebrospinal fluid (CSF) pressure secondary to a CSF leakage and consequent descent of the brain into the foramen magnum. Diagnosing SIH can be difficult due to its overlapping findings with Arnold-Chiari type 1 Malformation (CM1) where the cerebellar tonsils herniate into the foramen magnum. The similarity of both conditions calls for a more reliable imaging technique to localize the CSF leak which could narrow the differential diagnosis and aid in choosing the correct treatment. Here, we present a case of a 28-year-old female, ten weeks post-partum with symptoms similar to SIH. MRI of the brain was remarkable for tonsillar herniation below the foramen magnum. Literature was reviewed for additional neuroradiology techniques that would aid in narrowing our differential diagnosis. Interestingly, computed tomography-, digital subtraction-, and magnetic resonance myelography with intrathecal gadolinium are the preferred techniques for diagnosis of high flow and low flow CSF leaks, respectively. These modalities further aid in choosing the correct treatment while avoiding complications. Literature suggests that treatment for CM1 involves posterior fossa decompression, whereas the mainstay of treatment for SIH involves an epidural blood patch (EBP). Thus, our patient was treated with an EBP and recovered without complication.

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“…Other accompanying features involve vertigo, tinnitus, visual disturbances such as blurred vision or bitemporal hemianopia, dysgeusia, hearing loss, gait ataxia, radicular arm pain, and cranial nerve deficits, such as diplopia, most frequently due to VI palsy, facial weakness, or numbness [1,2,7,11,[23][24][25]. Although much rarer, cognitive decline [26], parkinsonism [27], chorea [28], quadriplegia [29], seizures [2], Meniere-like syndrome [30], hyperprolactinemia, and galactorrhea [3], as well as positional loss of consciousness and coma due to diencephalic herniation [31], have been also reported. In rare cases, focal back pain may reveal the site of CSF leakage [11].…”

Section: Clinical Presentationmentioning

confidence: 99%

Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment

et al. 2021

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Background Spontaneous intracranial hypotension (SIH) is characterized by positional headache caused by low CSF pressure, without any major traumatic event. Optimal treatment is still debated; epidural blood patch (EBP) is usually used after unsuccessful conservative treatment with variable efficacy and potentially severe complications. Although steroids have been reported to be beneficial, their effectiveness is still controversial, and more clinical evidence is needed. Case presentation A 37-year-old woman was admitted to the neurology department due to severe orthostatic headache with nausea over the last 5 days. No trauma history or spinal manipulation were mentioned. On arrival, neurological examination, brain CT, and laboratory investigation were normal. Intracranial hypotension was clinically suspected, and lumbar puncture revealed low opening pressure. Brain MRI demonstrated pachymeningeal gadolinium enhancement and distended and rounded dural venous sinuses, while cervicothoracic spine MRI revealed thoracic CSF leakage, leading to SIH diagnosis. The patient was treated with high-dose intravenous methylprednisolone, with complete clinical resolution within 24 h. Conclusions Our case, combined with literature evidence, supports the high-dose intravenous corticosteroids as a reasonable treatment option in selected cases, before trying EBP or surgical repair. Randomized clinical trials are needed, in order to optimize SIH patients’ outcomes.

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Sagging brain causing postural loss of consciousness: a case of severe spontaneous intracranial hypotension

Cited by 5 publications

References 21 publications

The status of diagnosis and treatment to intracranial hypotension, including SIH

The status of diagnosis and treatment to intracranial hypotension, including SIH

Spontaneous Intracranial Hypotension Presenting as a "Pseudo-Chiari 1"

Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment

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