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

  • Matsuzaki Ryo
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Nemoto Masaaki
    Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University
  • Masuda Hiroyuki
    Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University
  • Mikai Masataka
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Nakata Chie
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Fuchinoue Yutaka
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Uchino Kei
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Terazono Sayaka
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Harada Masashi
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Kondo Kosuke
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Harada Naoyuki
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University
  • Sugo Nobuo
    Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University

Bibliographic Information

Other Title
  • 慢性硬膜下血腫を合併した特発性低髄液圧症候群により切迫脳ヘルニアをきたした1例
  • マンセイコウマク カケッシュ オ ガッペイ シタ トクハツセイ テイズイエキアツ ショウコウグン ニ ヨリ セッパク ノウ ヘルニア オ キタシタ 1レイ

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Abstract

<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>

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