Suspected Low-Pressure Hydrocephalus Caused by Spinal Drainage after Subarachnoid Hemorrhage

Abstract

Background: Hydrocephalus induced by low cerebrospinal fluid (CSF) pressure is extremely rare and sporadically reported. Subarachnoid hemorrhage, head trauma, and spinal drainage were reported to be the causative factors for surgical treatments.Case Description: A 33-year-old male with subarachnoid hemorrhage caused by right vertebral artery aneurysm rupture developed a headache. A trapping surgery was performed, and a spinal drain was inserted from the lumbar L4/5 for subarachnoid hemorrhage washout.On postoperative day 3, increase in subdural fluid accumulation at the posterior fossa craniotomy site and narrowing of the cerebellar sulci appeared in addition to mild enlargement of the ventricles. The patient complained of a headache during head elevation. Low-pressure hydrocephalus (LPH) was suspected. The spinal drain was removed, the headache was relieved, and cerebral ventriculomegaly disappeared. The subsequent clinical course was good.The patient was discharged 3 weeks after the surgery. Discussion: LPH is a rare disease caused by various factors and is treated by correcting liquorrhea or overdrainage, if any. Otherwise, drainage at a negative CSF pressure is necessary.Its symptoms and image findings are similar to those of intracranial hypertension and normalpressure hydrocephalus. This paper reports a suspected LPH case caused by spinal drainage following subarachnoid hemorrhage with literature review.

Acute low-pressure hydrocephalus in aneurysmal subarachnoid hemorrhage

“…11,[21][22][23] Similarly, lumbar punctures and lumbar drainage have been discussed as triggering factors of aLPH. 10 Other pathophysiological mechanisms, such as a disconnection of the ventricular system from the cortical subarachnoid space as well as a decreased elasticity of the brain, have been discussed in the literature. 6,9,21,23 However, none of these theories could fully and convincingly explain the occurrence of aLPH in the systematic review by Keough et al 11 The higher rate and extension of IVH in these patients supports the theory of Rekate et al of a ventricular system isolated from the subarachnoid space.…”

“…Despite an increase in reports in recent years, the overall number of publications on this condition remains limited. [5][6][7][8][9][10] This ABBREVIATIONS aLPH = acute low-pressure hydrocephalus; CTA = CT angiography; DCI = delayed cerebral ischemia; DSA = digital subtraction angiography; EVD = external ventricular drain; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ICU = intensive care unit; IQR = interquartile range; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; TCD = transcranial Doppler ultrasonography; VPS = ventriculoperitoneal shunt; WFNS = World Federation of Neurosurgical Societies.…”

Low-/Negative-Pressure Hydrocephalus: To Understand the Formation Mechanism from the Perspective of Clinicians

“…In addition, SAH and surgery-induced increase in brain compliance may also impair CSF buffering capacity. 22 SAH from aneurysm rupture may also hinder the the CSF flow between the ventricles and the SAS; however, this may not be the main pathogenic factor. Based on the reported cases, CSF leakage or low SAS pressure may be the main pathogenic factors of LPH/NePH.…”

Oxidative Stress and Intracranial Hypertension after Aneurysmal Subarachnoid Hemorrhage

“…It should be noted that CSF over drainage and compensatory brain hyperemia can result in the malabsorption of CSF due to increased intracranial venous pressure and impaired CSF outflow. Therefore, impaired CSF circulation may lead to the aggravation of clinical symptoms and even coma, which can be reversed by immediately quitting the drainage [ 92 ]. The simultaneous monitoring of ICP and lumbar pressure was previously used as a treatment strategy to avoid lumbar over drainage by identifying progressive pressure gradients in advance [ 92 ].…”

“…Therefore, impaired CSF circulation may lead to the aggravation of clinical symptoms and even coma, which can be reversed by immediately quitting the drainage [ 92 ]. The simultaneous monitoring of ICP and lumbar pressure was previously used as a treatment strategy to avoid lumbar over drainage by identifying progressive pressure gradients in advance [ 92 ]. With the development of technologies in new external drainage systems, it is now possible to regulate flow while monitoring ICP [ 93 ].…”