Neurological Deterioration Following Bilateral Burr-Hole Drainage for Chronic Subdural Hematoma: A Case Report| Stephy Publishers

 


SOJ Medical and Clinical Case Reports - (SOJMCCR) | Stephy Publishers


Abstract

Background: Spontaneous intracranial hypotension (SIH) is a relatively rare but known pathology that results in brain herniation or sagging due to CSF hypovolemia. SIH can commonly be misdiagnosed when occurring with other pathologies including chronic subdural hematoma (CSDH). Neurological decline caused by SIH is rare, but is often rapid and much more severe.

Case description: A 69-year-old man was delivered to the emergency department for loss of consciousness and mild left hemiparesis. Brain computed tomography (CT) revealed increased density over basal cisterns suggestive of subarachnoid hemorrhage (SAH), and CSDH. Cerebral angiography showed dural arteriovenous fistula, but there was no apparent cerebral aneurysm. We first performed trans-arterial embolization using n-butyl cyanoacrylate, followed by bilateral hematoma evacuation. A postoperative CT showed that CSDH was evacuated, but the subdural space was filled with free air. A subsequent CT examination revealed mild re-accumulation of CSDH without significant brain compression. On postoperative day 14 the patient became progressively lethargic, for which he was transferred to the intensive care unit. As gadolinium-enhanced magnetic resonance imaging and radionuclide cisternography suggested the leakage of cerebrospinal fluid, an epidural catheter was inserted in the head- down positioned patient and an epidural infusion of saline was given for 3 days. The patient stabilized and regained consciousness over 2 weeks. The patient became neurologically intact with imaging showing almost complete parenchymal expansion and resolution of subdural fluid collection.

Conclusion: This is an instructive case because the patient deteriorated after the surgery for CSDH, but it is also a unique case because the deterioration occurred over 14 days. This report emphasizes the possibility that SIH should be taken into consideration when there is an unknown reason for early CSDH recurrence and neurological deterioration.

Keywords

Spontaneous intracranial hypotension, Continuous epidural saline infusion, Chronic subdural hematoma, Impaired consciousness

Abbreviations

SIH: Spontaneous Intracranial Hypotension, CSF: Cerebrospinal Fluid, CSDH: Chronic Subdural Hematoma, CT: Computed Tomography, MRI: Magnetic Resonance Imaging, SAH: Subarachnoid Hemorrhage,AVF: Arteriovenous Fistula

Introduction

Spontaneous intracranial hypotension (SIH) is the result of abnormally low intracranial pressure and most commonly manifests as postural headaches.1 SIH is a relatively rare but known pathology that results in brain herniation or sagging due to cerebrospinal fluid (CSF) hypovolemia.2-5 However, SIH can commonly be misdiagnosed, when occurring with other pathologies attributed to Chiari malformations, compression from subdural hematomas, or possible malignancies leading to leptomeningeal enhancement.6 Neurological decline caused by SIH is rarely reported, but is often rapid and much more severe. Several reports have noted that lumbar drainage placed to assist brain relaxation during treatment of aneurysms causes unexplained neurological decline with imaging evidence of brain herniation.2,7-9 In this report, our case showed relatively delayed onset of the exacerbation of consciousness after a bilateral hematoma evacuation, and improvement of neurological status following continuous infusion of saline into the epidural space.

Case Presentation

A 69-year-old man without apparent event of head trauma was presented to the department of otolaryngology for a 2-year history of tinnitus. Magnetic resonance imaging (MRI) showed bilateral fluid collection suspected of chronic subdural hematoma (CSDH). The patient was then referred to our department for further examination and treatment at 2 weeks prior to hospitalization. Because there was no neurological abnormality, we decided to have regular follow-ups. However, he was delivered to the emergency department for loss of consciousness on the day of admission.


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