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Spontaneous intracranial hypotension and venous sinus thrombosis
  1. Claire M Rice1,
  2. Shelley A Renowden2,
  3. David R Sandeman3,
  4. David A Cottrell1
  1. 1Department of Neurology, Frenchay Hospital, Bristol, UK
  2. 2Department of Neuroradiology, Frenchay Hospital, Bristol, UK
  3. 3Department of Neurosurgery, Frenchay Hospital, Bristol, UK
  1. Correspondence to Dr Claire M Rice, Department of Neurology, Frenchay Hospital, Bristol BS16 1LE, UK; c.m.rice{at}bristol.ac.uk

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Introduction

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.

Case report

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.

Figure 1

(A) Axial unenhanced cranial CT head scans from the initial presentation with headache and right-sided subdural effusion and (B, C) later following presentation in status epilepticus. (B) Demonstrates a small haematoma in the left posterior frontal lobe and (C) shows a moderately sized right-sided subdural effusion with mild mass effect. There is dense thrombus within an occluded superior sagittal sinus (arrowhead) and thrombus within a cortical vein (arrow).

Figure 2

(A–C) Sequential right internal carotid angiogram venous phase images demonstrate partial recanalisation of the superior sagittal sinus …

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