Management of an intracranial hypotension patient with diplopia as the primary symptom: A case report

doi:10.12998/wjcc.v9.i22.6544

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World Journal of Clinical Cases

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Case Report

World J Clin Cases. Aug 6, 2021; 9(22): 6544-6551
Published online Aug 6, 2021. doi: 10.12998/wjcc.v9.i22.6544

Management of an intracranial hypotension patient with diplopia as the primary symptom: A case report

Ting-Ting Wei, Hua Huang, Gang Chen, Fei-Fang He

Ting-Ting Wei, Gang Chen, Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China

Hua Huang, Fei-Fang He, Department of Pain Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China

Author contributions: Wei TT and Chen G reviewed the literature and contributed to manuscript drafting; Huang H and He FF analyzed, interpreted the imaging findings, and drafted the manuscript; Wei TT, Huang H, He FF, and Chen G were responsible for the revision of the manuscript for important intellectual content; All authors issued final approval for the version to be submitted.

Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.

Conflict-of-interest statement: The authors declare that there is no conflict of interest in this article.

CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

Corresponding author: Gang Chen, PhD, Chief Doctor, Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, No. 3 Qingchun Road, Hangzhou 310003, Zhejiang Province, China. chengang120@zju.edu.cn

Received: April 11, 2021
Peer-review started: April 20, 2021
First decision: May 11, 2021
Revised: May 18, 2021
Accepted: May 26, 2021
Article in press: May 26, 2021
Published online: August 6, 2021
Processing time: 107 Days and 12 Hours

Abstract

BACKGROUND

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.

CASE SUMMARY

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.

CONCLUSION

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.

Keywords: Cranial nerve VI palsy; Epidural blood patch; Intracranial hypotension; Subdural hematoma; Case report

Core Tip: Intracranial hypotension (IH) is an uncommon disorder of cerebrospinal fluid (CSF) hypovolemia due to spontaneous or iatrogenic spinal CSF leakage, and is easily being misdiagnosed or missed as it can be associated with a large diversity of clinical signs. To the best of our knowledge, this is the first case in the literature describing a patient of having IH with diplopia as his initial and primary complaint, and demonstrating the efficacy of repeated epidural blood patch therapy in managing a patient with multiple sites of CSF leakage in the spine complicated with cranial nerve VI injury and subdural hematomas.