Intracranial hypotension complications [Neurosurgery Wiki]

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====== Intracranial hypotension complications ======

Undiagnosed [[intracranial hypotension]] can result in several [[complication]]s including [[subdural hematoma]] (SDH), [[subarachnoid hemorrhage]] (SAH), [[dural venous sinus thrombosis]] (CVT), [[cranial nerve palsy]], and [[stupor]] resulting from sagging of the brain. It is rare to see all the complications in one patient. Furthermore, imaging of the brain vasculature may reveal incidental asymptomatic small aneurysms. Given the combination of these imaging findings and a severe [[headache]], the patients are often confused to have a primary [[subarachnoid hemorrhage]].
((Ade S, Moonis M. Intracranial hypotension with multiple complications: an
unusual case report. Case Rep Neurol Med. 2013;2013:913465. doi:
10.1155/2013/913465. Epub 2013 Nov 13. PubMed PMID: 24324901; PubMed Central
PMCID: PMC3845395.
)).

===== Subarachnoid hemorrhage =====

Dilation and rupture of intracranial venous structures might play significant roles in [[Spontaneous intracranial hypotension]] (SIH) combined with SAH. We should be alert to SIH patients who develop a new persistent severe headache without relief after lying down or a suddenly changed state of consciousness
((Cao Y, Na W, Su H, Wang X, Dong Z, Yu S. Subarachnoid hemorrhage caused by spontaneous intracranial hypotension: two rare cases report. Int J Neurosci. 2021 Feb 8:1-5. doi: 10.1080/00207454.2021.1881094. Epub ahead of print. PMID: 33499724.)).
----
[[Cerebrospinal fluid]] [[overdrainage]] and [[cerebrospinal fluid hypovolemia]] due to [[lumbar drainage]] could induce severe fatal complications, which include [[transtentorial herniation]] and [[infratentorial hemorrhage]]. 

The incidence of [[subdural hematoma]] (SDH) associated with SIH is about 20%
((Schievink WI, Maya MM, Moser FG, Tourje J. Spectrum of subdural fluid collections in spontaneous intracranial hypotension. J Neurosurg 2005; 103: 608-613.))
((Lai TH, Fuh JL, Lirng JF, Tsai PH, Wang SJ. Subdural haematoma in patients with spontaneous intracranial hypotension. Cephalalgia 2007; 27: 133-138.)).

===== Cranial nerve palsy =====
[[Cranial nerve palsy]] (CNP) secondary to [[Cerebrospinal fluid shunt]] is less familiar to us as a result of its rarity in incidence and insidiousness in presentation.


From June 2012 to February 2015, 5 of 347 consecutive patients with CNPs secondary to different CSF diversion procedures were treated at The First Hospital of Jilin University, Changchun, Jilin, China.

A systematic PubMed search of published studies written in English for patients developing CNPs after CSF diversion procedures from January 1950 to June 2015 was conducted.

Overall, 29 studies and 5 patients of the current series totaling 53 CNPs met the inclusion criteria. CN II, III, IV, V, VI, VII and VIII were got involved in 2 (3.8%), 2 (3.8%), 5 (9.4%), 1 (1.9%), 44 (83.0%), 4 (7.5%) and 1 (1.9%) patients respectively. Thirty-eight patients (71.7%) developed CNPs following inadvertent lumbar puncture, 8 (15.1%) following lumbar drainage, and 7 (13.2%) following ventriculoperitoneal shunt. Forty-eight (90.6%) patients got resolved completely.

The proposed mechanism of CNP after CSF diversion procedure is cerebrospinal fluid hypovolemia and subsequent downward displacement of the brain and traction and distortion of the vascular and peripheral neural structures. As a result of its distinct anatomic characteristics rather than long intracranial course, CN VI is most commonly affected. With early recognition and timely conservative management, most patients could get favorable recovery 
((Li G, Zhu X, Zhang Y, Zhao J, Han Z, Hou K. Cranial nerve palsy secondary to Cerebrospinal fluid shunt. Clin Neurol Neurosurg. 2016 Apr;143:19-26. doi: 10.1016/j.clineuro.2016.02.010. Epub 2016 Feb 9. PubMed PMID: 26882270.)).

===== Remote cerebellar hemorrhage ======
Dural opening with [[cerebrospinal fluid hypovolemia]] seems to be an important factor contributing to [[remote cerebellar hemorrhage]] (RCH) following cervical spinal surgery. 

It has been suggested that one way to prevent RCH is to avoid extensive perioperative loss of CSF, by paying attention to surgical [[position]]ing during [[spinal surgery]]. Huang et al also underline the importance of early diagnosis and CSF expansion in the early treatment of RCH
((Huang PH, Wu JC, Cheng H, Shih YH, Huang WC. Remote cerebellar hemorrhage
after cervical spinal surgery. J Chin Med Assoc. 2013 Oct;76(10):593-8. doi:
10.1016/j.jcma.2013.02.006. Epub 2013 Jun 5. PubMed PMID: 23746536.
)).

===== Case reports =====

Ade et al presented a patient with [[spontaneous intracranial hypotension]] (SIH) who had an incidental [[ophthalmic artery aneurysm]] on MR imaging, and this presentation led to [[coiling]] of the aneurysm. The key aspect in the history of “[[postural headache]]s” was missed, and this led to life-threatening complications and unnecessary [[intervention]]s. Revisiting the history and significant improvement in symptoms following an epidural blood patch resulted in the diagnosis of SIH.

They strongly emphasize that appropriate history taking is the key in the diagnosis of SIH and providing timely treatment with an [[epidural blood patch]] could prevent potentially life-threatening complications
((Ade S, Moonis M. Intracranial hypotension with multiple complications: an
unusual case report. Case Rep Neurol Med. 2013;2013:913465. doi:
10.1155/2013/913465. Epub 2013 Nov 13. PubMed PMID: 24324901; PubMed Central
PMCID: PMC3845395.
)).

===== References =====