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Spontaneous intracranial hypotension (SIH) is an uncommon but well-recognised cause of orthostatic headache. Subdural effusions or haemorrhage are well-known complications of SIH. However, that SIH may lead to venous sinus thrombosis, a cause of high-pressure headache, is not widely appreciated. We present a case of spontaneous intracranial hypotension complicated by subdural effusion with subsequent venous sinus thrombosis, intracranial venous haemorrhage and status epilepticus. We discuss the importance of early detection of spontaneous intracranial hypotension along with its management and potential complications.
A previously fit and well 75-year-old man presented in status epilepticus. Three weeks before, he had developed a low-pressure headache during exercise at the gym. A CT scan of the head performed shortly after headache onset had shown a right-sided subdural effusion that was managed conservatively.
Following the unwitnessed collapse, he was airlifted to the regional neurosciences centre. His Glasgow Coma Scale score was 3 (E1, M1 and V1) on arrival. He was intubated and ventilated. There was no optic disc swelling or localising signs. He had no known predisposition to thrombosis. An unenhanced CT head scan demonstrated a right-sided effusion (subsequently drained), hyper-density of the superior sagittal sinus and left-sided parietal haemorrhage (figure 1). Seizure-management, anti-coagulation, intracranial pressure control and thromboaspiration were undertaken (figure 2). Unfortunately, the patient died following further intracranial haemorrhage.
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