• Journal of Dental Anesthesia and Pain Medicine
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• v.18 no.4
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• pp.255-259
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• 2018

Sudden headache onset may rarely be caused by spontaneous intracranial hypotension (SIH). Other associated symptoms in patients with SIH are nausea, vomiting, vertigo, hearing alteration, and visual disturbance. This case report describes a 43-year-old female diagnosed with SIH who developed diplopia after resolution of an abrupt-onset headache, which was managed with conservative treatments, including bed rest and hydration. She was also diagnosed with secondary right sixth cranial nerve palsy. Although conservative management relieved her headache, the diplopia was not fully relieved. Application of an autologous epidural blood patch successfully relieved her diplopia, even after 14 days from the onset of visual impairment.

• The Korean Journal of Pain
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• v.12 no.1
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• pp.152-156
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• 1999

Spontaneous intracranial hypotension (SIH) is a rare syndrome which causes postural headache associated with low cerebrospinal fluid (CSF) pressure, without preceding events such as lumbar puncture, back trauma, operative procedure or illness. The headche is usually accompanied by nausea, vomiting, tinnitus, neck stiffness, vertigo, photophobia and in rare cases diplopia, transient visual obscuration. Brain MRI may show subdural effusion, downward displacement of brain and diffuse and continuous meningeal enhancement when enhanced by gadolinium. Low opening pressure was shown through lumbar puncture. The value of protein and cell count of CSF may be slightly elevated. This syndrome usually resolves itself spontaneously or with strict bed rest. When the headache is persistent or incapacitating, more aggressive treatment may be necessary. We treated two cases of SIH in which epidural blood patch produced immediate and complete relief of the symptoms.

• Journal of Korean Neurosurgical Society
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• v.65 no.6
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• pp.868-874
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• 2022

Spontaneous intracranial hypotension (SIH) most commonly manifests as bilateral subdural hematoma (SH). SIH cases mostly resolve spontaneously but further treatment would be needed via blind epidural blood patch (EBP). Cerebrospinal fluid (CSF) leakage in EBP-refractory cases can be treated surgically only if the localization of CSF leakage is detectable but it cannot be possible in most of the cases. Also surgical evacuation of SH secondary to SIH (SH-SIH) is not favorable without blocking the CSF leakage. Thus the management of these patients is a challenge and alternative treatment options are needed. Although middle meningeal artery embolization (MMAE) is an effective treatment option in non-SIH SH, there is no report about its application in the treatment of SH-SIH. We present two cases of SH-SIH which their clinical and radiological findings were completely resolved by bilateral MMAE treatment.

• Journal of Korean Neurosurgical Society
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• v.39 no.1
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• pp.68-71
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• 2006

Spinal subdural hematoma[SSDH] is rare disease. Furthermore, it rarely occurs as a complication of intracranial surgery. There are few case reports which describing SSDH after craniotomy. Although the exact pathogenetic mechanism is obscure, some investigators propose that downward migration of intracranial hematoma by the effect of gravity is one of the cause of SSDH, and which is commonly suggested. But others propose that cerebrospinal fluid[CSF] hypotension is an another possible mechanism In this paper, we report two cases of SSDH after clipping of an aneurysmal neck.

• Journal of Korean Neurosurgical Society
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• v.55 no.3
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• pp.170-172
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• 2014

Percutaneous epidural neuroplasty (PEN) is a known interventional technique for the management of spinal pain. As with any procedures, PEN is associated with complications ranging from mild to more serious ones. We present a case of intracranial subdural hematoma after PEN requiring surgical evacuation. We review the relevant literature and discuss possible complications of PEN and patholophysiology of intracranial subdural hematoma after PEN.

• Journal of Korean Neurosurgical Society
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• v.29 no.2
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• pp.240-248
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• 2000

Objective : Spontaneous intracranial hypotension is a rarely reported syndrome of spontaneous postural headache associated with low CSF pressure and has rarely been demonstrated radiographically or surgically. But recently, it is being recognized with increasing frequency. The purpose of this study was to characterize clinical and imaging features, etiologic factors, and outcome in the spontaneous intracranial hypotension. Patients and Methods : We reviewed our experience with documented cases of spontaneous intracranial hypotension in 5 consecutive patients with orthostatic headaches from April 1998 to April 1999. Results : The mean age was 41 years(from 35 to 49 years). All patients had postural headaches, which were completely alleviated by recumbency position. Nausea, neck pain, horizontal diplopia, photophobia, and blurred vision were noted in some of the patients. Brain MRI showed diffuse pachymeningeal gadolinium enhancement, subdural collections of fluid, and descent of the brain. The opening pressure from lumbar puncture was $4cmH_2O$ or less in three of five patients whereas the opening pressure was within normal range in two patients. All patients underwent radioisotope cisternography and computerized tomographic myelography. On radioisotope cisternography, CSF leakage was suspected at the level of cervical area(1 patient), upper thoracic area(2 patients), mid-thoracic area(1 patient). Computed tomography myelography revealed extraarachnoid accumulation of contrast media(compatible finding with CSF leakage) at the level of cervical or thoracic area. In all patients, the symptoms resolved in response to supportive measures or epidural blood patch(1 patient). Conclusion : Spontaneous spinal CSF leakage is increasingly recognized as a cause of spinal postural headache. Most CSF leaks are located at the cervicothoracic junction or in the thoracic spine and can be demonstrated by variable diagnostic method. The condition is usually self-limiting and its prognosis is typically good.

• The Korean Journal of Nuclear Medicine
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• v.32 no.6
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• pp.482-489
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• 1998

Purpose: Radionuclide cisternography may be helpful in understanding pathophysiology of postural head-ache and low CSF pressure in patients with spontaneous intracranial hypotension. The purpose of this study was to characterize radionuclide cisternographic findings of spontaneous intracranial hypotension. Materials and Methods: The study population consists of 15 patients with spontaneous intracranial hypotension. Diagnosis was based on their clinical symptoms and results of lumbar puncture. All patients underwent radionuclide cisternography following injection of 111 to 222 MBq of Tc-99m DTPA into the lumbar subarachnoid space. Sequential images were obtained between 112 hour and 24 hour after the injection of Tc-99m DTPA. Radioactivity of the bladder, soft tissue uptake, migration of radionuclide in the subarachnoid space, and extradural leakage of radionuclide were evaluated according to the scan time. Results: Radionuclide cisternogram showed delayed migration of radionuclide into the cerebral convexity (14/15), increased soft tissue uptake (11/15), and early visualization of bladder activity at 30min (6/10) and 2hr (13/13). Cisternography also demonstrated leakage site of CSF in 4 cases and 2 of these were depicted at 30min. Epidural blood patch was done in 11 patients and headache was improved in all cases. Conclusion: The characteristic findings of spontaneous intracranial hypotension were delayed migration of radionuclide and early visualization of the soft tissue and bladder activity. These scintigraphic findings suggest that CSF leakage rather than increased CSF absorption or decreased production may be the main pathophysiology of spontaneous intracranial hypotension. Early and multiple imaging including the bladder and soft tissue is required to observe the entire dynamics of radionuclide migration.

• Journal of Korean Neurosurgical Society
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• v.58 no.2
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• pp.144-146
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• 2015

Postdural punctural headache (PDPH) following spinal anesthesia is due to intracranial hypotension caused by cerebrospinal fluid (CSF) leakage, and it is occasionally accompanied by an intracranial hematoma. To the best of our knowledge, an intracranial chronic subdural hematoma (CSDH) presenting with an intractable headache after a cervical epidural steroid injection (ESI) has not been reported. A 39-year-old woman without any history of trauma underwent a cervical ESI for a herniated nucleus pulposus at the C5-6 level. One month later, she presented with a severe headache that was not relieved by analgesic medication, which changed in character from being positional to non-positional during the preceding month. Brain magnetic resonance imaging revealed a CSDH along the left convexity. Emergency burr-hole drainage was performed and the headache abated. This report indicates that an intracranial CSDH should be considered a possible complication after ESI. In addition, the event of an intractable and changing PDPH after ESI suggests further evaluation for diagnosis of an intracranial hematoma.

• The Korean Journal of Pain
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• v.20 no.2
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• pp.235-239
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• 2007

Spontaneous intracranial hypotension (SIH) is believed to be a benign disease. However, numerous studies have reported serious complications related to SIH, including subdural hematoma. In this case report, a 54-year-old male patient visited the emergency room with orthostatic headache. A brain magnetic resonance imaging (MRI) study showed diffuse mild thickening and enhancement of pachymeninges, with a suspicious minimal amount of subdural fluid collected in the left posterior parietal area. His orthostatic headache showed no improvement with conservative treatment; but his pain was almost completely relieved after two trials of cervical epidural blood patch. On the 74th day after the onset of his pain, the patient showed a drowsy mental status and slurred speech when he visited the pain clinic. Brain computerized tomography indicated a left subdural hemorrhage, and he underwent emergency operation to drain the SDH. In conclusion, pain clinicians should pay attention to abrupt changes in mental status as well as continuous headache, for the early diagnosis of SDH in SIH patients.

• The Korean Journal of Pain
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• v.11 no.2
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• pp.338-342
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• 1998

Postural headache due to spontaneous intracranial hypotension occurs without any diagnostic lumbar puncture, myelography, cranial or spinal injury, or spinal anesthesia. The clinical characteristics of the syndrome are disappearance of the headache or a notable decrease in its severity with recumbency, the finding of meningeal enhancement and subdural fluid collection on brain MRI, the pleocytosis and the increased CSF protein concentration. We report a case of a 40-year-old woman who exhibited the signs and symptoms of postural headache due to low CSF pressure. Her headache started suddenly at the occiput and radiated to frontal head. Magnetic resonance imaging (MRI) of her brain showed enhancement of the meninges and subdural fluid collection. Intrathecal radionuclide cisternography showed the delayed appearance of the isotope in the cranium and the minimal CSF leak at the left upper thoracic region. Her headache was relieved completely after a lumbar (L2-L3) epidural injection of 12 ml of autologous blood and remained asymptomatic.