Abstract
Background
Low cerebrospinal fluid volume is typically diagnosed in patients presenting with positional headaches. However, severe intracranial hypotension and brain sagging may cause orthostatic coma. We present a case that illustrates this uncommon presentation.
Method
Case report.
Results
A 50-year-old man presented with orthostatic headaches and then developed bilateral subdural hematomas. Following unilateral subdural hematoma evacuation, the patient became gradually drowsier and more confused. Upon transfer to our hospital, he would become comatose each time he was placed in the upright position. Successful epidural patch at the level of a spontaneous cerebrospinal fluid leak documented by myelography resulted in complete resolution of his orthostatic symptoms despite reaccumulation of the subdural fluid collection.
Conclusions
Evacuation of subdural fluid collections may be detrimental in patients with low CSF volume by exacerbating the intracranial hypotension. Extreme brain sagging may lead to anatomical distortion of the diencephalon and brainstem resulting in coma.
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References
Frerrante E, Arpino I, Citterio A, Savino A. Coma resulting form spontaneous intracranial hypotension treated with the epidural blood patch in the Trendelenburg position pre-medicated with acetazolamide. Clin Neurol Neurosurg. 2009;111(8):699–702.
Schievink WI, Moser FG, Pikul BK. Reversal of Coma with an injection of glue. Lancet. 2007;369:1402.
Evan RW, Mokri B. Spontaneous intracranial hypotension resulting in coma. Headache. 2002;42(2):159–60.
Mokri B. The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology. 2001;56(12):1746–8.
Pleasure SJ, Abosch A, et al. Spontaneous intracranial hypotension resulting in stupor caused by diencephalic compression. Neurology. 1998;50(6):1854–7.
Savoiardo M, Minati L, et al. Spontaneous intracranial hypotension with deep brain swelling. Brain. 2007;130(Pt 7):1884–93.
Schievink WI, Palestrant D, et al. Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm. J Neurosurg. 2009;110(3):521–4.
Whiteley W, Al-Shahi R, et al. Spontaneous intracranial hypotension causing confusion and coma: a headache for the neurologist and the neurosurgeon. Br J Neurosurg. 2003;17(5):456–8.
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Dhillon, A.K., Rabinstein, A.A. & Wijdicks, E.F.M. Coma from Worsening Spontaneous Intracranial Hypotension After Subdural Hematoma Evacuation. Neurocrit Care 12, 390–394 (2010). https://doi.org/10.1007/s12028-009-9323-8
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DOI: https://doi.org/10.1007/s12028-009-9323-8