Impending cerebral herniation due to spontaneous intracranial hypotension in a patient with chronic subdural hematoma: A case report

Matsuzaki Ryo, Nemoto Masaaki, Masuda Hiroyuki, Mikai Masataka, Nakata Chie, Fuchinoue Yutaka, Uchino Kei, Terazono Sayaka, Harada Masashi, Kondo Kosuke, Harada Naoyuki, Sugo Nobuo

doi:10.24723/jsne.26.2_197

<p> We herein report a patient with idiopathic spontaneous intracranial hypotension (SIH) and a difficult‒to‒treat chronic subdural hematoma (CSDH) who suffered from impending cerebral herniation. A 45‒year‒old Japanese male who was treated in another hospital with chief complaints of headache, dizziness, and tinnitus arrived at our hospital due to the lack of symptomatic improvement. His symptoms worsened when he stood up, and he was admitted to our hospital with suspicious SIH. Computed tomography revealed bilateral subdural hygroma, and magnetic resonance imaging with gadolinium demonstrated diffuse dural enhancement. Cisternal scintigraphy led to the suspicion of cerebrospinal fluid leakage at the level of the upper thoracic spine. Conservative treatment was unsuccessful, but an epidural saline infusion and epidural blood patch led to rapid improvement. However, the patient’s consciousness deteriorated and he developed right oculomotor nerve palsy. Repeat treatment with an epidural saline infusion and epidural blood patch did not improve his symptoms. An additional injection of saline and autologous blood did not improve the level of consciousness, whereas burr‒hole drainage led to the recovery of consciousness. The patient underwent postoperative rehabilitation and was discharged on the 56th day of hospitalization. In this patient’s case, the initial mechanism was a decrease in intracranial pressure due to SIH, which was balanced by the pressure from the CSDH. However, we speculate that the increase in the CSDH led to an increase in intracranial pressure. Therefore, closing the leak site with epidural blood patch might have led to impending cerebral herniation due to a rapid increase in intracranial pressure. As illustrated by this patient’s case, simultaneous treatment should be considered in patients with SIH accompanying CSDH who might rapidly deteriorate, and a meticulous neurological follow‒up is critical for successful outcomes in these patients. The safest treatment is the simultaneous administration of an epidural blood patch and burr‒hole drainage.</p>

Impending cerebral herniation due to spontaneous intracranial hypotension in a patient with chronic subdural hematoma: A case report

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