Spontaneous intracranial hypotension, hygromata and haematomata
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* D G Healy
* P J Goadsby
* N D Kitchen
* T Yousry
* M G Hanna

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.

## CASE REPORT

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.

![Figure 1](http://casereports.bmj.com/https://casereports.bmj.com/content/casereports/2009/bcr.2007.132019/F1.medium.gif)

[Figure 1](http://casereports.bmj.com/content/2009/bcr.2007.132019/F1)

Figure 1 Serial coronal MRI FLAIR scans. There are approximately 1 month intervals between each scan. (A) Bilateral subdural hygromata with downward displacement of the brain and both distortion of the mesencephalic and left-sided uncal herniation. The cortical veins are dilated and there is subtle compression of the lateral ventricles. (B) Unchanged radiological appearance, with probable worsening of the uncal herniation. (C) Maturation of constituents in the right-sided hygroma and a new left-sided subdural haematoma. (D) Bilateral subdural haematomata including new left-sided bleeding. (E) Overall resolution in the size of both hygromata/haematomata. (F) Complete resolution of both collections. The uncal herniation has resolved and there is re-dilatation of the lateral ventricles with loss of the prominent cortical veins.

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.

## DISCUSSION

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.

## Acknowledgments

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](http://jnnp.bmj.com/cgi/content/full/79/4/442)

## Footnotes

*   **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.

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2.  Lusins JO, Levy ER. MRI documentation of haemorrhage into post traumatic subdural hygroma. Mt Sinai J Med 1993;60:161–2.
    
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