Anestéziológia a intenzívna medicína 1-2/2025
Spontaneous intracranial hypotension: a case report
Spontaneous intracranial hypotension is a remarkable and rare cause of persistent headache. It is characterized by orthostatic headache, low cerebrospinal fluid pressure, and diffuse pachymeningeal enhancement on gadolinium-enhanced brain magnetic resonance imaging. The authors describe a case of a 46-year-old man with chronic vertebrogenic complaints who, after completing rehabilitation procedures, developed headaches associated with verticalization, accompanied by nausea and vomiting. Based on brain and spine MRI, the condition was assessed as spontaneous intracranial hypotension with suspected cerebrospinal fluid leak in the epidural space in the Th4/5 segment. The patient underwent analgesic and muscle relaxant treatment, as well as bilateral sphenopalatine ganglion blockade. During repeated hospitalization in the neurological clinic, the patient developed quantitative impairment of consciousness and manifestations of organic psychosyndrome. A follow-up CT scan of the brain showed a bifrontal subdural hematoma and a follow-up MRI myelography showed a dural defect in the L2/3 space, for which the anaesthesiologist applied an epidural blood patch with temporary alteration of consciousness. To highlight the subdural collection on the left hemisphere with expansive behaviour on the follow-up CT scan of the brain, the neurosurgeon performed trepanoevacuation of the hematoma. Due to persistent headache and neurological deficit despite the above interventions, the patient was transferred to the authors’ clinical department, where he underwent targeted blood patch in the epidural space Th4/5 and in the posterior epidural space Th11/12 under fluoroscopic control. Due to variable consciousness and trunk symptoms, a CT perimyelographic examination was performed in the range from the posterior fossa to the sacral region of the spine with intrathecal administration of contrast medium. Examination revealed a localized cerebrospinal fluid leak at the level of C2/3 and C3/4, a small leak also in the Th4/5 area on the left, and continued protrusion of the cerebellar tonsils through the foramen magnum. After management of associated sepsis, transforaminal administration of fibrin into the cervical foramina C2/3 and C3/4 was performed, with subsequent resolution of the headache, with the possibility of rehabilitation and verticalization of the patient.
Keywords: spontaneous intracranial hypotension, headache, CT myelography, magnetic resonance imaging of the brain, cerebrospinal fluid, subdural hygroma and hematoma, blood patch, case report
