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We describe our management of complex spontaneous intracranial hypotension associated with bilateral subdural hygromata. The accompanying images illustrate evolutionary changes over a 6-month period, including late subdural haemorrhage into resolving hygromata. This case demonstrates that conservative management has a place in the management of some patients.
A 65-year-old man presented to us with a severe fronto-occipital throbbing headache. A few days earlier he had noticed a “twinge” in the back of his neck and saw a chiropractor. His headaches were postural, relieved by lying flat and accompanied by meningitic features, including photophobia and neck stiffness.
MRI of the brain, performed 6 days after onset of the headache, demonstrated bilateral subdural collections over the cerebral convexities and tentorium (fig 1). The dura was diffusely thickened and enhanced with contrast (not shown). The brain was displaced downward through the foramen magnum resulting in mesencephalic deformity and left-sided uncal herniation. MRI of the spine was normal.
Spontaneous intracranial hypotension (SIH) was diagnosed. We hypothesised that the neck “twinge” resulted from a tear in the cervical dura. CSF radio-nucleotide studies, or blood patching, were not performed because of concerns about further trans-tentorial displacement. Serial MRI scans, at 1 month intervals, were performed (fig 1). A recrudescence in the severity of his headache, 2 months after onset, was explained by the development of a new subdural haematoma (fig 1C). The patient was treated conservatively by bed rest and analgesia. Intravenous caffeine, given early in the course of symptoms, was of moderate benefit. A complete clinical and radiological recovery occurred over the following 3–4 months.
In patients with SIH, dural hyperaemia and subdural CSF collections are probably explained by the Monro–Kellie doctrine: intracranial dural venous congestion replaces loss of CSF volume in the spine. The late occurrence of subdural haematoma is well recognised and is reported in as many as 20% of patients.1 2 This may result from rupture of stretched congested bridging veins, especially in the context of trans-tentorial herniation.2
This case illustrates two important clinical lessons. Firstly, when the symptoms of SIH change in severity, or character, prompt re-imaging should exclude subdural haematoma. Secondly, some SIH can be managed conservatively, even in the presence of associated subdural haemorrhage. Whether an early blood patch could have prevented the late complication of subdural haemorrhage is unclear.
This article has been adapted from Healy D G, Goadsby P J, Kitchen N D, Yousry T, Hanna M G. Spontaneous intracranial hypotension, hygromata and haematomata Journal of Neurology, Neurosurgery and Psychiatry 2008;79:442
Competing interests: One of the co-authors (MGH) is deputy editor of J Neurol Neurosurg Psychiatry.
Patient consent: Informed consent was obtained for publication of the case details in this report.