Value of Targeted Epidural Blood Patch and Management of Subdural Hematoma in Spontaneous Intracranial Hypotension: Case Report and Review of the Literature

Background

Spontaneous intracranial hypotension (SIH) is a more common than previously noted condition (1–2.5 per 50,000 persons) typically caused by cerebrospinal fluid (CSF) leakage. Initial treatment involves conservative therapies, but the mainstay of treatment for patients who fail conservative management is the epidural blood patch (EBP). Subdural hematoma (SDH) is a common complication occurring with SIH, but its management remains controversial.

Methods

In this report, we discuss a 62-year-old woman who presented with a 5-week history of orthostatic headaches associated with nausea, emesis, and neck pain. Despite initial imaging being negative, the patient later developed classic imaging evidence characteristic of SIH. Magnetic resonance imaging was unrevealing for the source of the CSF leak. Radionuclide cisternography showed possible CSF leak at the right-sided C7-T1 nerve root exit site. After failing a blind lumbar EBP, subsequent targeted EBP at C7-T1 improved the patient's symptoms. Two days later she developed a new headache with imaging evidence of worsening SDH with midline shift requiring burr hole drainage. This yielded sustained symptomatic relief and resolution of previously abnormal imaging findings at 2-month follow-up.

Results

A literature review revealed 174 cases of SIH complicated by SDH. This revealed conflicting opinions concerning the management of this condition.

Conclusions

Although blind lumbar EBP is often successful, targeted EBP has a lower rate of patients requiring a second EBP or other further treatment. On the other hand, targeted EBP has a larger risk profile. Depending on the clinic situation, treatment of the SDH via surgical evacuation may be necessary.

Introduction

Spontaneous intracranial hypotension (SIH) is typically caused by a cerebrospinal fluid (CSF) leak, leading to an overall decrease in CSF volume. This can cause brain sagging with traction and distortion of the central nervous system and surrounding structures leading to the primary symptom of postural headaches. Undiagnosed, this condition may lead to other complications as severe as the development of subdural hematomas (SDHs), making proper recognition and treatment essential. Initial management may involve conservative measures, such as hydration and bed rest. If these measures fail, epidural blood patch (EBP) is the typical treatment of choice.1, 2 EBPs may be targeted, where the site of the CSF leak has been identified, or blind, in which the site of the leak need not be localized. Targeted EBPs may have greater risks, but conversely may be more effective than blind EBPs.³ In this report, we present a case of SIH in which both blind and targeted EBPs were used. Furthermore, during the prolonged course of treatment, simultaneous SDH formation occurred, which was ultimately evacuated by burr hole drainage. This article also investigates prior cases where simultaneous SDH was associated with SIH and summarizes the evolving opinion concerning the optimal management of these patients.