The domino effect of acephalgic spontaneous intracranial hypotension
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The domino effect of acephalgic spontaneous intracranial hypotension Umberto Pensato 1 & Fabrizio Giammello 2 & Tommaso Baldini 1 & Anna Zaniboni 3 & Laura Piccolo 3 & Giorgia Arnone 1,3 & Mauro Gentile 3 & Luigi Cirillo 4,5 & Luigi Simonetti 6 & Salvatore Isceri 6 & Andrea Zini 3 Received: 20 August 2020 / Accepted: 23 September 2020 # Fondazione Società Italiana di Neurologia 2020
Abstract Spontaneous intracranial hypotension results from a spinal CSF leak and usually presents with orthostatic headache, although acephalgic presentations have anecdotally been reported. The underlying low CSF volume, rarely, leads to serious complications such as cerebral venous thrombosis and coma. We report a patient presenting with cerebral venous thrombosis secondary to acephalgic spontaneous intracranial hypotension. An epidural blood patch was performed; nonetheless, the patient intracracal condition deteriorated to coma and neuroimages showed a deep brain swelling with midbrain distortion, subsequently complicated by intracranial pontine hemorrhage. Keywords Cerebral venous thrombosis . CSF leak . Epidural blood patch . Midbrain swelling . Deep brain swelling . Orthostatic headache
Introduction Spontaneous intracranial hypotension (SIH) results from low cerebrospinal fluid (CSF) volume, usually secondary to a spinal CSF leak [1]. Most patients present with orthostatic headache variably associated with other orthostatic symptoms [1].
Low CSF volume leads to brain sagging and venous engorgement, potentially resulting in serious complications such as cerebral venous thrombosis (CVT), intracranial hemorrhages, and coma [2, 3]. Thus, an appropriate treatment with epidural blood patch (EBP) should be commenced promptly in order to prevent neurological sequelae.
Umberto Pensato and Fabrizio Giammello contributed equally to this work. Clinical highlights • Spontaneous intracranial hypotension (SIH) rarely presents sine headache. • SIH may result in complications as cerebral venous thrombosis (CVT). • CVT without common risk factors should be screened for asymptomatic SIH. • Severe brain sagging may cause deep brain swelling and coma. * Andrea Zini [email protected]; [email protected]
4
Neuroradiology Unit, Bellaria Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
1
Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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DIMES, Department of Specialty, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
2
Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
6
Neuroradiology Unit, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
3
Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Nigrisoli 2, 40133 Bologna, Italy
Neurol Sci
Hereby, we report a patient with acephalgic SIH which eventually led to a series of complications, including CVT and deep brain
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