Intracranial hypotension - post spinal puncture

Case contributed by Dr Igor Strahovnik

Presentation

Headache and vomitus that was contributed to serous meningitis. Girl had a lumbar spinal tap.

Patient Data

Age: 14

Present features of intracranial hypotension:

  • probably small subdural effusion bilaterally frontopolar and perimesencephalic on precontrast sequences (or could be just dural thickening)
  • diffuse dural enhancement (there is no leptomeningeal enhancement that would indicate meningitis)
  • hypotension causes rounding and engorgement of venous sinuses
  • convex contour and hyperemia of hypohysis
  • small forward angling of brainstem

Case Discussion

Clinical outcome

Girl had a worsening of postural headache after spinal tap that slowly passed away in the following two weeks.

Pathology

Intracranial hypotension is caused by CSF reduction:

  • CSF leak
    • most are spontaneous
      • probably spontaneous meningeal tears that occur with higher incidence in connective tissue disorders (Marfan, Ehler Danlos,...)
    • idiopathic procedure like spinal tap, myelography, spinal surgery, spinal anesthesia or excessive CSF shunting
    • trauma
  • medical causes probably because of smaller CSF production (rare)
    • dehydration
    • diabetic coma
    • uremia

Headache is thought to arise because of loss of CSF cushion effect with traction on intracranial structures or/and in part to venous vasodilatation.

Treatment

Usually conservative treatment with rest, hydration, caffein intake and paracetamol, if severe steroids.

If conservative treatment fails epidural blood patches of leakage is usually effective. Surgical ligature is usually not needed.

PlayAdd to Share

Case Information

rID: 36598
Case created: 1st May 2015
Last edited: 19th Dec 2015
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.