3. โ Intracranial hypotension is a
neurological condition occurs due to
low CSF volume (volumetric
intracranial hypotension), pressure
(barometric intracranial hypotension)
or both attributable to its leak through
a dural defect.
โ Normal CSF pressure is 80 โ 180 mm H2O.
โ Normal CSF volume is 160 ml.
4. โ Intracranial hypotension was first
described in 1938 by the German
neurologist, George Schaltenbrand, who
named it aliquarrhoea or absent CSF
which was later replaced by hypo-
liquarrhoea (decreased CSF).
5. (1) Post-dural puncture headache.
(2) CSF fistula headache (after surgical procedure or trauma).
(3) Headache attributed to SIH.
โ Headache attributed to low CSF pressure
6. โ It is the sine qua non of SIH which
worsens in upright position and
disappear on recumbency
โ Neck stiffness.
โ Cranial nerve palsies due to their
downward traction.
โ Spinal radicular syndromes.
โ Galactorrhea.
โ Dural sinus thrombosis.
โ Coma or encephalopathy.
7. โ Headache in temporal relation to low CSF
pressure or CSF leakage.
โ Either or both of the following:
1. CSF pressure < 60 mm H2O.
2. Evidence of CSF leakage on imaging.
โ Absence of a procedure or trauma known to
be able to cause CSF leakage.
8. โ SIH is strongly linked to ruptured meningeal
diverticula in heritable connective tissue
disorders e.g. Marfanโs syndrome, Ehlers-
Danlos, or autosomal dominant polycystic
kidney syndrome.
โ The dural diverticula are usually located at the
exits of spinal nerves roots and usually rupture
during vigorous exercise, straining, coughing,
sneezing. etc.
9. โ Intracranial hypotension constitutes 0.5โ1%
of all headache presentations to the ER
with yearly incidence of 2โ5 /100,000.
โ Initial misdiagnosis is common which subject
the patient to unnecessary procedures,
work-up and treatments.
โ The mean time of correct diagnosis is up to
13 months from symptomsโ onset.
19. โ The prognosis is variable, many patients
may have only mild symptoms, some
patients may deteriorate with cranial
nerve palsies, sinus thrombosis, large
vessel strokes, or even encephalopathy
and coma.
20. (1) Conservative measures for small dural defects,
included strict supine with ample hydration and
analgesia.
(2) Non-targeted epidural injection of 10โ20 ml
venous blood (may be repeated).
(3) CT guided targeted blood patch or fibrin glue at
the leak site.
(4) Surgical repair of the dural defect with ligation of
the diverticulum by aneurysm clip.
21. (1) Recent onset orthostatic headache.
(2) Bilateral subdural hematoma or hygroma.
(3) Subdural hematoma in young.
(4) Subdural recollection after evacuation.
(5) Imaging characters of vertical brain descent.
(6) Unexplained persistent cranial nerve palsies.
22. โ Headache due to SIH may looses its
orthostatic characters with time especially
when subdural collections take place.
โ Epidural blood patch alone is followed by
resolution of the subdural hematoma in 85%
of cases. Moreover, subdural hematoma
evacuation before closure of the CSF leak
will result in recollection and increased
brain sagging by the skull defect.
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