Low-Pressure Hydrocephalus and Shunt Malfunction Following a Lumbar Puncture in an Adult Reversed by an Epidural Blood Patch

BACKGROUND: Low-pressure hydrocephalus (LPH) is a relatively rare condition, and its presentation is similar to the classically seen high-pressure hydrocephalus, with headaches, cranial nerve dysfunction, ataxia, and disturbances of consciousness. Cerebral cerebrospinal fluid loss in the presence of altered brain viscoelastic properties has previously been suggested as the pathophysiologic process leading to ventriculomegaly, despite low or negative intracranial pressures and patent shunts. More recently, cerebral venous overdrainage has been proposed as a possible explanation in the pathogenesis of LPH, although its connection to lumbar punctures in patients with shunts has not been contemplated yet. The effectiveness of epidural blood patch in the management of post-lumbar puncture LPH has been shown in children but has not been reported in adults. CASE DESCRIPTION: Herein we detail 2 episodes of shunt malfunction in a 30-year-old female patient with a history of hydrocephalus related to a posterior fossa tumor diagnosed during childhood. In both instances, imaging studies demonstrated ventricular dilation along with perimedullary cistern enlargement and brainstem distortion, which occurred following a lumbar puncture despite a patent shunt. A lumbar blood patch was effective in both episodes, enabling resolution of the ventriculomegaly and a good outcome. CONCLUSIONS: A blood patch can be efficient in adults with post-lumbar puncture LPH. Some symptoms may be explained by brainstem compression caused by enlarged cerebrospinal fluid spaces at the skull base. The role of cerebral venous overdrainage in the setting of post-lumbar puncture LPH is further supported.