• Case reports
• Epidural blood patch
• Intracranial hypotension
• Subdural hematoma
• Headache

• Deterioration
• Drainage
• Epidural blood patch
• Spontaneous intracranial hypotension
• Subdural hematoma

• Male
• Humans
• Female
• Intracranial Hypotension/complications
• Intracranial Hypotension/diagnostic imaging
• Retrospective Studies
• Hematoma, Subdural/complications
• Hematoma, Subdural/diagnostic imaging
• Drainage/adverse effects
• Blood Patch, Epidural

• Blood patch, epidural
• Cerebrospinal fluid leak
• Hematoma, subdural
• Intracranial hypotension
• Magnetic resonance image
• Myelography

Intracranial hypotension (IH) is a disorder involving cerebrospinal fluid (CSF) hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed, especially in these patients without the prototypical manifestation of an orthostatic headache. At present, the management of IH with both cranial nerve VI palsy and bilateral subdural hematomas (SDHs) is still unclear.

A 67-year-old male Chinese patient complained of diplopia on the left side for one and a half mo. Computed tomography revealed bilateral SDHs and a midline shift. However, neurotrophic drugs were not effective, and 3 d after admission, he developed a non-orthostatic headache and neck stiffness. Enhanced magnetic resonance imaging revealed dural enhancement as an additional feature, and IH was suspected. Magnetic resonance myelography was then adopted and showed CSF leakage at multiple sites in the spine, confirming the diagnosis of having IH. The patient fully recovered following multiple targeted epidural blood patch (EBP) procedures.

IH is a rare disease, and to the best of our knowledge, IH with diplopia as its initial and primary symptom has never been reported. In this study, we also elucidated that it could be safe and effective to treat IH patients with associated cranial nerve VI palsy and bilateral SDHs using repeated EBP therapy.

• Cranial nerve VI palsy
• Epidural blood patch
• Intracranial hypotension
• Subdural hematoma
• Case report

Patients with computed tomography (CT) findings consistent with subarachnoid hemorrhage without evidence of hemorrhage following autopsy or cerebrospinal fluid testing are termed to have pseudosubarachnoid hemorrhage (pSAH).

A systematic review of literature was conducted based on the preferred reporting items for systematic reviews and meta-analysis statement. Studies were evaluated for associated cause of pSAH, imaging modality used in assessment, method of confirmatory testing, and clinical outcome.

Fifty studies were included in qualitative analysis including 197 cases of pSAH. Systematic review revealed 23 studies including 110 patients with pSAH attributed to hypoxic-ischemic brain injury following cardiac arrest. Three studies were included in meta-analysis that quantitatively analyzed differences in CT densities in patients with pSAH and true subarachnoid hemorrhage (true SAH). A random effects model meta-analysis showed a statistically significant decrease in densities in the Sylvian fissure in patients with pSAH compared to true SAH and a statistically significant decrease in densities in adjacent parenchyma in patients with pSAH compared to true SAH. Systematic review further revealed 32 patients with pSAH associated with spontaneous intracranial hypotension, 11 patients with pSAH related to infectious etiologies, 15 patients with pSAH associated with subdural hemorrhage, 20 cases of pSAH related to hyperhemoglobinemia, 2 cases related to valproate toxicity, and individual cases related to hyponatremia, diabetic ketoacidosis, sudden infant death syndrome, cerebellar infarction, and dialysis disequilibrium syndrome.

This study is the first systematic review of causes, diagnostic modalities, and outcomes in patients who present with pSAH. A diagnosis of pSAH may be considered following assessment of CT densities following cardiac arrest.

• Cardiac arrest
• False subarachnoid hemorrhage
• Pseudosubarachnoid hemorrhage
• Systematic review

Spontaneous intracranial hypotension (SIH) is usually a benign disease which mostly present as orthostatic headache and resolves by conservative treatment or epidural blood patch. However, in severe cases large subdural hematoma or brain caudal herniation can progress to brain herniation and neurologic complications. We introduce a rare case of SIH which presented as acute mental deterioration with unilateral acute subdural hematoma. A 60 years old female visited to emergency room for stuporous mental change and unilateral acute subdural hematoma. Decompressive craniectomy and hematoma removal was performed to release brain herniation and increased intracranial pressure. There was temporary improvement of consciousness, but sustained leakage of cerebrospinal fluid (CSF) and caudal brain herniation worsened patient's condition. After recognizing that CSF leakage and hypovolemia was the underlying disease, emergent epidural blood patch and early cranioplasty was performed. After treatment CSF volume was normalized and patient recovered completely without neurologic deficits. Acute mental deterioration with unilateral subdural hematoma is a rare presentation for SIH. Treatment strategy for subdural hematoma with concomitant SIH patients, should be planned carefully with concerns to CSF hypovolemia and intracranial pressure.

• Cerebrospinal fluid leak
• Epidural blood patch
• Intracranial hypotension
• Subdural hematoma

• Hemorrhage
• Intracranial hypotension
• Spontaneous
• Subdural

• Spontaneous intracranial hypotension; Low cerebrospinal fluid opening pressure; Body mass index; Magnetic resonance imaging

• Cerebrospinal fluid
• Epidural blood patch
• Headache
• Spontaneous intracranial hypotension
• Subdural hematoma

Cerebrospinal fluid hypovolemia (CSFH) is sometimes associated with chronic subdural hematomas (CSHs). Affected patients often develop enlargement and recurrence of the CSH, even if appropriate treatments such as epidural blood patch (EBP) and/or burr-hole surgery for the CSH are performed. This situation may lead to subclinical coagulopathy, including low coagulation factor XIII (CFXIII) activity. We retrospectively analyzed whether CFXIII activity was involved in the development of CSHs and post-treatment exacerbation of CSHs in patients with CSFH.

We diagnosed CSFH by radioisotope (RI), magnetic resonance imaging (MRI) and computed tomography (CT) findings, and CSH by CT and/or MRI findings. The plasma CFXIII activity was assessed on admission. All patients with CSFH initially received conservative treatments. When these treatments were ineffective, the patients underwent EBP and/or CSH surgery according to previously reported therapeutic strategies.

Among 206 patients with CSFH, 19 developed CSHs. Fourteen patients with a thin hematoma underwent EBP and three with a thick hematoma underwent CSH surgery immediately after EBP on the same day. We were unable to diagnose two patients with CSFH at the time of admission, and one of these two patients underwent repeated CSH surgery before obtaining the correct diagnosis. Seven patients (36.8%) developed CSH exacerbation after the treatment. The CFXIII activity was significantly lower in patients with than without a CSH (42.1% vs. 12.8%, respectively; P = 0.003). The CFXIII activity was significantly lower in patients with than without post-treatment CSH exacerbation (P = 0.046). All five patients with low CFXIII activity who developed CSH exacerbation received intravenous injection of CFXIII and had no recurrence of CSH after the additional treatment.

In patients with CSFH, low CFXIII activity is one of the risk factors for both the development of a CSH and the post-treatment exacerbation CSH.

• Cerebrospinal fluid hypovolemia
• chronic subdural hematoma
• coagulation factor
• coagulation factor XIII
• intractable chronic subdural hematoma

• emergency department
• misdiagnosis
• spontaneous intracranial hypotension
• subdural hematoma

• spontaneous intracranial hypotension
• chronic subdural hematoma
• epidural blood patch

• Adult
• Aged
• Female
• Hematoma, Subdural, Chronic/diagnostic imaging
• Hematoma, Subdural, Chronic/etiology
• Humans
• Intracranial Hypotension/complications
• Intracranial Hypotension/diagnostic imaging
• Magnetic Resonance Imaging
• Male
• Middle Aged
• Retrospective Studies
• Young Adult

Subdural haematoma (SDH) is a potentially life-threatening complication in patients with spontaneous intracranial hypotension (SIH). In serious cases, SIH patients who present with SDHs develop neurological deficits, a decreased level of consciousness, or cerebral herniation, and may even require an urgent neurosurgical drainage. Despite numerous publications on SDHs, few report its potential risk factors in patients with SIH. In this study, we retrospectively investigated 93 consecutive SIH patients and divided them into an SDH group (n = 25) and a non-SDH (NSDH) group (n = 68). The clinical and radiographic characteristics of these 93 patients were analyzed, and then univariate analysis and further multiple logistic regression analysis were performed to identify the potential risk factors for the development of SDHs. The univariate analysis showed that advanced age, male gender, longer clinical course, dural enhancement, and the venous distension sign were associated with the development of SDHs. However, multivariate analysis only included the latter three factors. Our study reveals important radiological manifestations for predicting the development of SDHs in patients with SIH.

• Adult
• Aged
• Female
• Hematoma, Subdural/etiology
• Humans
• Intracranial Hypotension/complications
• Male
• Middle Aged
• Risk Factors
• Young Adult

• Epidural blood patch
• Spontaneous intracranial hypotension
• Subdural hematoma

Supine recumbence has been widely performed to prevent post-lumbar puncture headache (PLPH). However, the optimal duration of supine recumbence is controversial. The aim of the study is to compare the occurrence of PLPH according to the duration of supine recumbence in patients with neurological disorders.

A non-equivalent control/experimental pre-/post-test study design was used. Seventy consecutive patients were prospectively enrolled between July 2007 and July 2008. Thirty-five patients underwent supine recumbence for four hours after lumbar puncture (Group 1) and 35 patients underwent supine recumbence for one hour (Group 2).

The overall frequency of PLPH was 31.4%. The frequency of PLPH was not significantly different between the Group 1 (28.6%) and Group 2 (34.3%) (P = 0.607). In patients with PLPH, the median severity (P = 0.203) and median onset time of PLPH (P = 0.582) were not significantly different between the two groups. In a logistic regression analysis, the previous history of post-lumbar puncture headache was a significant risk factor for the occurrence of PLPH (OR = 11.250, 95% CI: 1.10-114.369, P = 0.041).

Our study suggests that short duration (one hour) of supine recumbence may be as efficient as long duration (four hours) of supine recumbence to prevent PLPH.

Headache is a common complication of lumbar puncture (LP). Although in most cases post-LP headaches are not severe and have a benign course, they can also be a manifestation of a potentially life-threatening complication such as subdural hematoma (SDH).

We describe a patient in whom a massive SDH developed after LP and cerebrospinal fluid (CSF) drainage, which were performed during the diagnostic evaluation of freezing of gait.

SDH should not be excluded from the differential diagnosis of headache following LP, especially when there is a loss of CSF.

• cerebrospinal fluid drainage
• freezing of gait
• headache
• lumbar puncture
• subdural hematoma