Journal of Neurosurgery

March 2009 / Vol. 110 / No. 3 / Pages 521-524

Vascular Disorder

Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm
Case report

1Department of Neurosurgery, The Maxine Dunitz Neurosurgical Institute; 2Department of Neurology and 3Imaging Medical Group, Cedars-Sinai Medical Center, Los Angeles; and 4Valley Neuroscience Institute, Glendale, California
Abbreviation used in this paper: GCS = Glasgow Coma Scale.
Address correspondence to: Wouter I. Schievink, M.D., Department of Neurosurgery, Cedars-Sinai Medical Center, 8631 West Third Street, Suite 800E, Los Angeles, California 90048. email: .
Related Articles
By Keywords:
cerebral aneurysm, intracranial hypotension, spinal fluid leak

Abstract

Spontaneous spinal CSF leaks are best known as a cause of orthostatic headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray–white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.

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  1. Wouter I. Schievink, M.D., Marc S. Schwartz, M.D., M. Marcel Maya, M.D., Franklin G. Moser, M.D., M.M.M., and Todd D. Rozen, M.D.. Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks. Journal of Neurosurgery 0:0, 1-6 Abstract | Full Text | PDF (2768 KB) 
  2. Wouter I. Schievink, M.D., and M. Marcel Maya, M.D.. Frequency of intracranial aneurysms in patients with spontaneous intracranial hypotension. Journal of Neurosurgery 0:0, 1-3 Abstract | Full Text | PDF (810 KB) 
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  7. D.R. Hadizadeh, A. Kovacs, H. Tschampa, R. Kristof, J. Schramm, H. Urbach. (2010) Postsurgical Intracranial Hypotension: Diagnostic and Prognostic Imaging Findings. American Journal of Neuroradiology 31:1, 100-105. Online publication date: 1-Jan-2010. [CrossRef]
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