1/5. Intrathecal saline infusion in the treatment of obtundation associated with spontaneous intracranial hypotension: technical case report.OBJECTIVE AND IMPORTANCE: Spontaneous intracranial hypotension is an increasingly recognized cause of postural headache. However, appropriate management of obtundation caused by intracranial hypotension is not well defined. CLINICAL PRESENTATION: A 43-year-old man presented with postural headache followed by rapid decline in mental status. Imaging findings were consistent with the diagnosis of spontaneous intracranial hypotension, with bilateral subdural hematomas, pachymeningeal enhancement, and caudal displacement of posterior fossa structures and optic chiasm. INTERVENTION: Despite treatment with lumbar epidural blood patch, worsening stupor necessitated intubation and mechanical ventilation. Contrast-enhanced magnetic resonance imaging and computed tomographic myelography of the spine failed to demonstrate the site of cerebrospinal fluid fistula. The enlarging subdural fluid collections were drained, and a ventriculostomy was performed. Postoperatively, the patient remained semicomatose. To restore intraspinal and intracranial pressures, intrathecal infusion of saline was initiated. After several hours of lumbar saline infusion, lumbar and intracranial pressures normalized, and the patient's stupor resolved rapidly. Repeat computed tomographic myelography accomplished via C1-C2 puncture demonstrated a large ventrolateral T1-T3 leak, which was treated successfully with a thoracic epidural blood patch. Follow-up magnetic resonance imaging demonstrated resolution of intracranial hypotension, and the patient was discharged in excellent condition. CONCLUSION: Spontaneous intracranial hypotension may cause a decline of mental status and require lumbar intrathecal saline infusion to arrest or reverse impending central (transtentorial) herniation. This case demonstrates the use of simultaneous monitoring of lumbar and intracranial pressures to appropriately titrate the infusion and document resolution of intracranial hypotension. Maneuvers aimed at sealing the cerebrospinal fluid fistula then can be performed in a less emergent fashion after the patient's mental status has stabilized.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
2/5. Spontaneous intracranial hypotension causing confusion and coma: a headache for the neurologist and the neurosurgeon.Spontaneous intracranial hypotension presenting with confusion and coma has rarely been reported. A case is presented and the clinical features of spontaneous intracranial hypotension are discussed.- - - - - - - - - - ranking = 5keywords = coma (Clic here for more details about this article) |
3/5. Reversible coma: a rare presentation of spontaneous intracranial hypotension.BACKGROUND: Spontaneous intracranial hypotension (SIH) is a well-recognized neurologic disorder that typically presents with orthostatic headaches, low cerebral spinal fluid pressures and distinct abnormalities on magnetic resonance imaging. methods: We present a case of a rare presentation of SIH. RESULTS: A 49-year-old man presented with a two week history of orthostatic headaches that rapidly progressed to encephalopathy and coma, requiring intubation. neuroimaging revealed abnormalities typical of SIH; diffusely enhancing pachymeninges, subdural fluid collections, and descent of the brain. Treatment with an epidural blood patch reversed his coma within minutes. Following a second blood patch, the patient became asymptomatic. No cerebral spinal leak could be identified on magnetic resonance imaging or on a nuclear medicine technetium cerebral spinal fluid flow study. At six month follow-up, he remained symptom free. CONCLUSION: The mechanism of coma in SIH is presumed to be compression of the diencephalon from downward displacement of the brain. Although it is very unusual for patients with SIH to present with coma, it is important to recognize since the coma may be reversible with epidural blood patches.- - - - - - - - - - ranking = 9keywords = coma (Clic here for more details about this article) |
4/5. Spontaneous intracranial hypotension resulting in coma: case report.OBJECTIVE: Spontaneous intracranial hypotension is a potentially severe condition characterized by a distinct clinical picture caused by low cerebrospinal fluid pressure. Although coma has been reported previously as a presentation of this condition, this is the first report in which misdiagnosis of this condition and unwarranted surgery led to coma. CLINICAL PRESENTATION: A 62-year-old man presented with a history of headache, and cranial magnetic resonance imaging showed bilateral chronic subdural hematomas. After evacuation of the hematoma, the patient's condition deteriorated into a state of profound depression of consciousness. Repeated cranial computed tomographic scans showed intracranial air, and intracranial pressure monitoring showed negative recording. Spinal magnetic resonance imaging demonstrated epidural cerebrospinal fluid leaks at the middle and lower thoracic levels. INTERVENTION: Epidural blood patch resulted in almost immediate improvement in the patient's condition, and he was fully awake 24 hours later. CONCLUSION: This case report expands the presently known clinical spectrum of this uncommon and generally benign illness.- - - - - - - - - - ranking = 6keywords = coma (Clic here for more details about this article) |
5/5. Multiple simultaneous intracerebral hemorrhages following accidental massive lumbar cerebrospinal fluid drainage: case report and literature review.Multiple simultaneous intracerebral hemorrhages (ICH) are uncommon. We report the case of an 80-year-old woman with previous diagnosis of normal pressure hydrocephalus and who was brought to our hospital with altered mental status and urinary incontinence. Medical history of hypertension, hematological disorders or severe head trauma was absent. platelet count and coagulation profile were unremarkable. An initial head computed tomography (CT) showed sulcal enlargement and ventricular dilatation, but no evidence of ICH. A tap test indicated as a guide to case selection for shunt surgery accidentally resulted in cerebrospinal fluid (CSF) overdrainage. The patient presented sudden neurological deterioration, with sluggishly responsive pupils and generalized tonic-clonic seizures. A new head CT demonstrated multiple supra and infratentorial ICH. The patient became comatose and had a fatal course. Hence, CSF overdrainage may either cause or precipitate multiple simultaneous ICHs, affecting both the infratentorial and supratentorial regions.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |