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Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions

Intracranial hypotension (IH) is a relatively common condition associated with low cerebrospinal (CSF) pressure. The most typical symptom is orthostatic headache, although neurological deficits and changes in the level of consciousness, such as encephalopathy, stupor, and coma, may also occur. Uncom...

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Autores principales: Chung, Douglas J, Liounakos, Jason, Abrams, Kevin, Siomin, Vitaly
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Cureus 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292696/
https://www.ncbi.nlm.nih.gov/pubmed/32542144
http://dx.doi.org/10.7759/cureus.8089
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author Chung, Douglas J
Liounakos, Jason
Abrams, Kevin
Siomin, Vitaly
author_facet Chung, Douglas J
Liounakos, Jason
Abrams, Kevin
Siomin, Vitaly
author_sort Chung, Douglas J
collection PubMed
description Intracranial hypotension (IH) is a relatively common condition associated with low cerebrospinal (CSF) pressure. The most typical symptom is orthostatic headache, although neurological deficits and changes in the level of consciousness, such as encephalopathy, stupor, and coma, may also occur. Uncomplicated CSF hypotension headaches generally resolve with rest, hydration, and analgesia. However, persistent cases may require an epidural blood patch (EBP) for resolution. Our report presents the case of a 50-year-old male with a history of intravenous (IV) drug abuse, positive for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) antibodies, who was admitted for new-onset headache and brain magnetic resonance imaging (MRI) findings suggesting CSF hypotension. The patient subsequently developed altered mental status with agonizing respirations, prompting intubation and admission to the intensive care unit (ICU) with neurosurgery consult. The initial exam revealed fixed and dilated pupils, suggestive of severe IH with brain herniation and the decision was made to proceed with an emergent intrathecal infusion with intraparenchymal intracranial pressure (ICP) monitoring, combined with EBP. A substantial clinical improvement was noted following the procedure. Within 45 minutes, the patient’s mental status improved to normal and pupillary dilation and areflexia were no longer observed. While the procedure may need to be repeated in cases of late deterioration, this report provides evidence that intrathecal bolus saline infusion with simultaneous ICP monitoring may be considered an effective measure to treat extreme cases of IH with associated brain herniation. If performed in a timely fashion, improvement of ICP numbers, and clinical resolution can be quite rapid.
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spelling pubmed-72926962020-06-14 Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions Chung, Douglas J Liounakos, Jason Abrams, Kevin Siomin, Vitaly Cureus Neurosurgery Intracranial hypotension (IH) is a relatively common condition associated with low cerebrospinal (CSF) pressure. The most typical symptom is orthostatic headache, although neurological deficits and changes in the level of consciousness, such as encephalopathy, stupor, and coma, may also occur. Uncomplicated CSF hypotension headaches generally resolve with rest, hydration, and analgesia. However, persistent cases may require an epidural blood patch (EBP) for resolution. Our report presents the case of a 50-year-old male with a history of intravenous (IV) drug abuse, positive for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) antibodies, who was admitted for new-onset headache and brain magnetic resonance imaging (MRI) findings suggesting CSF hypotension. The patient subsequently developed altered mental status with agonizing respirations, prompting intubation and admission to the intensive care unit (ICU) with neurosurgery consult. The initial exam revealed fixed and dilated pupils, suggestive of severe IH with brain herniation and the decision was made to proceed with an emergent intrathecal infusion with intraparenchymal intracranial pressure (ICP) monitoring, combined with EBP. A substantial clinical improvement was noted following the procedure. Within 45 minutes, the patient’s mental status improved to normal and pupillary dilation and areflexia were no longer observed. While the procedure may need to be repeated in cases of late deterioration, this report provides evidence that intrathecal bolus saline infusion with simultaneous ICP monitoring may be considered an effective measure to treat extreme cases of IH with associated brain herniation. If performed in a timely fashion, improvement of ICP numbers, and clinical resolution can be quite rapid. Cureus 2020-05-13 /pmc/articles/PMC7292696/ /pubmed/32542144 http://dx.doi.org/10.7759/cureus.8089 Text en Copyright © 2020, Chung et al. http://creativecommons.org/licenses/by/3.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Neurosurgery
Chung, Douglas J
Liounakos, Jason
Abrams, Kevin
Siomin, Vitaly
Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions
title Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions
title_full Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions
title_fullStr Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions
title_full_unstemmed Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions
title_short Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions
title_sort extreme intracranial hypotension with brain herniation treated with repeat bolus intrathecal infusions
topic Neurosurgery
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292696/
https://www.ncbi.nlm.nih.gov/pubmed/32542144
http://dx.doi.org/10.7759/cureus.8089
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