Life-threatening spontaneous intracranial hypotension responding to epidural blood patch
Editor—Following the recent case series of spontaneous intracranial hypotension (SIH) as an indication for epidural blood patch,1 we report a severe case presenting with a decreasing level of consciousness, leading to coma and requiring tracheal intubation. This patient was also treated successfully with an epidural blood patch.A 68-year-old man presented with a 5-day history of worsening frontal headache and vomiting. His Glasgow Coma Scale, initially 14/15, deteriorated to 9/15 over the next 24 h. Brain imaging with CT scan was reported as showing increased attenuation in the basilar cisterns and the tentorium cerebelli, initially suggestive of subarachnoid haemorrhage. Subsequent review, however, identified these findings as SIH2 and led us to perform an MRI scan. By this time he was agitated and had developed apnoeic episodes, bradycardia and hypertension. He was intubated and ventilated to enable MRI scanning and facilitate further management. The MRI scan showed bilateral, 8 mm subdural fluid collections overlying the frontal lobes, with effacement of cortical sulci and basal cisterns. Post-gadolinium enhanced images showed pachymeningeal enhancement supporting a diagnosis of SIH.3 He was transferred to the Intensive Care Unit and treated with an epidural blood patch consisting of 20 ml of sterile blood injected at the L3/L4 level. Twelve hours later his sedation was stopped, to allow him to wake and be extubated. His conscious level then recovered over the next few hours to a GCS of 15/15 with complete resolution of symptoms.
The literature suggests that the breach of the dura in SIH is most often at the cervical or thoracic level.4 In our patient, the site of the dural tear was unknown. Exactly how the ‘blind’ epidural blood patch causes benefit in these cases is unclear but, as in those reported by Buguet-Brown and colleagues,1 we found it to be rapidly effective.
Bath, UK
*E-mail: dinesh.shrikrishna{at}nhs.net
References
1 Buguet-Brown ML, Le Guluche Y, Vichard A, et al. Spontaneous intracranial hypotension: a recent indication for epidural blood patch. Br J Anaesth 2006; 96:668–9
2 Schievink WI, Maya MM, Tourje J, et al. Pseudo-subarachnoid haemorrhage: a CT finding in spontaneous intracranial hypotension. Neurology 2005; 65:135–7
3 Chiapparini L, Ciceri E, Nappini S, et al. Headache and intracranial hypotension: neuroradiological findings. Neurol Sci 2004; 25:Suppl 3, S138–41
4 Schievink WI, Meyer FB, Atkinson JL, et al. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 1996; 84:598–605[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||