Spontaneous intracranial hypotension with bilateral subdural hemorrhage: Is conservative management adequate?
A 35 year old Chinese man experienced severe generalized headache over a couple of days. The headache was throbbing in nature and maximum in the posterior parietal regions. In addition, he also complained of double vision, neck pain and dizziness; however, denied having nausea or vomiting. The headaches were aggravated when he assumed an upright posture (sitting or standing) and alleviated when lying down. He did not have preceding history of strenuous physical activities such as heavy weight lifting, trauma or a lumbar puncture procedure. Neurological examination revealed bilateral mild restriction of lateral gaze (likely due to VI nerve involvement), which resulted in binocular diplopia on extreme horizontal gaze. His brain computed tomography with contrast was normal. MRI brain showed prominence of cortical veins and significant distension of dural venous sinuses raising the possibility of pachymeningitis without venous sinus thrombosis [Figure ,]. In addition, cervical spine MRI revealed engorged anterior epidural venous plexus at cranio cervical junction and upper cervical spine, with mild effacement of the subarachnoid space, raising the possibility of spontaneous intracranial hypotension secondary to cerebrospinal fluid (CSF) leak; however, no nerve root diverticula was noted. Repeated lumbar puncture (LP) failed to extract any CSF. Subsequently, LP under fluoroscopic guidance confirmed a low CSF pressure (5 cm of water). The routine CSF investigations for infective and inflammatory markers were all negative.\nHe was treated conservatively with strict bed rest, adequate hydration and analgesia. A radionuclide cisternography showed CSF leak at the junction of cervical 5 and cervical 6 (C6/ C7) vertebrae []. Treatment options including targeted epidural blood patch (EBP) were discussed; however, the patient opted for conservative management. He was discharged after a week. We had advised him to rest at home for another 2 weeks; however, he resumed normal activities on the very next day. Three days later, he presented again with severe headaches and worsening of diplopia. A repeat MRI brain showed bilateral subdural hematoma (SDH) []. Once again options of treatment were discussed with the patient and he decided for conservative management. He was continued on intravenous hydration, tablet caffeine and strict bed rest. After 2 weeks his headaches resolved completely and he was discharged well. He had further rest at home and resumed his routine duties 6 weeks after hospital discharge. He remained well and a follow-up CT scan done 3 months after discharge showed complete resolution of SDH. There has been no recurrence of symptoms since the last 14 months of follow-ups.