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

Case report

Restricted access

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.

Abbreviation used in this paper:GCS = Glasgow Coma Scale.
Article Information

Contributor Notes

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: SchievinkW@cshs.org.
Headings
References
  • 1

    Binder DKDillon WPFishman RASchmidt MJ: Intrathecal saline infusion in the treatment of obtundation associated with spontaneous intracranial hypotension: technical case report. Neurosurgery 51:8308372002

    • Search Google Scholar
    • Export Citation
  • 2

    Bloch JRegli L: Brain stem and cerebellar dysfunction after lumbar spinal fluid drainage: case report. J Neurol Neurosurg Psychiatry 74:9929942003

    • Search Google Scholar
    • Export Citation
  • 3

    Bousser MGFerro JM: Cerebral venous thrombosis: an update. Lancet Neurol 6:1621702007

  • 4

    Coche EPersu ACosnard GQuoidbach APirson Y: Multiple thoracic paraspinal meningeal cysts in autosomal dominant polycystic kidney disease. Am J Kidney Dis 41:E82003

    • Search Google Scholar
    • Export Citation
  • 5

    de Freitas GRBogousslavsky J: Risk factors of cerebral vein and sinus thrombosis. Front Neurol Neurosci 23:23542008

  • 6

    Francel PCPersing JACantrell RWLevine PANewman SA: Neurological deterioration after lumbar cerebrospinal fluid drainage. J Craniofac Surg 3:1451481992

    • Search Google Scholar
    • Export Citation
  • 7

    Given CA IIBurdette JHElster ADWilliams DW III: Pseudo-subarachnoid hemorrhage: a potential imaging pitfall associated with diffuse cerebral edema. AJNR Am J Neuroradiol 24:2542562003

    • Search Google Scholar
    • Export Citation
  • 8

    Graf CJGross CEBeck DW: Complications of spinal drainage in the management of cerebrospinal fluid fistula. J Neurosurg 54:3923951981

    • Search Google Scholar
    • Export Citation
  • 9

    Kelley GRJohnson PL: Sinking brain syndrome: craniotomy can precipitate brainstem herniation in CSF hypovolemia. Neurology 62:1572004

    • Search Google Scholar
    • Export Citation
  • 10

    Komotar RJMocco JRansom ERMack WJZacharia BEWilson DA: Herniation secondary to critical postcraniotomy cerebrospinal fluid hypovolemia. Neurosurgery 57:2862922005

    • Search Google Scholar
    • Export Citation
  • 11

    Mathew LKomotar R: Epidural blood patch for severe postoperative intracranial hypotension. J Neurosurg Anesthesiol 20:49522008

  • 12

    Pirson YChauveau DTorres V: Management of cerebral aneursysms in autosomal dominant polycystic kidney disease. J Am Soc Nephrol 13:2692762002

    • Search Google Scholar
    • Export Citation
  • 13

    Rainov NGHeidecke VBurkert W: Thoracic and lumbar meningocele in neurofibromatosis type 1. Report of two cases and review of the literature. Neurosurg Rev 18:1271341995

    • Search Google Scholar
    • Export Citation
  • 14

    Samadani UHuang JHBaranov DZager ELGrady MS: Intracranial hypotension after intraoperative lumbar cerebrospinal fluid drainage. Neurosurgery 52:1481512003

    • Search Google Scholar
    • Export Citation
  • 15

    Schievink WI: Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 295:228622962006

  • 16

    Schievink WILouy C: Precipitating factors of spontaneous spinal CSF leaks and intracranial hypotension. Neurology 69:7007022007

  • 17

    Schievink WIMaya MMMoser FTourje JTorbati S: Frequency of spontaneous intracranial hypotension in the emergency department. J Headache Pain 8:3253282007

    • Search Google Scholar
    • Export Citation
  • 18

    Schievink WIMaya MMTourje JMoser FG: Pseudo-subarachnoid hemorrhage: a CT-finding in spontaneous intracranial hypotension. Neurology 65:1351372005

    • Search Google Scholar
    • Export Citation
  • 19

    Schievink WIMoser FGPikul BK: Reversal of coma with an injection of glue. Lancet 369:14022007

  • 20

    Schievink WIParisi JEPiepgras DGMichels VV: Intracranial aneurysms in Marfan's syndrome: an autopsy study. Neurosurgery 41:8668701997

    • Search Google Scholar
    • Export Citation
  • 21

    Schievink WIRiedinger MMaya MM: Frequency of incidental intracranial aneurysms in neurofibromatosis type I. Am J Med Genet A 134A:45482005

    • Search Google Scholar
    • Export Citation
  • 22

    Schievink WITorres VE: Spinal meningeal diverticula in autosomal dominant polycystic kidney disease. Lancet 349:122312241997

  • 23

    Silver SMSterns RHHalperin ML: Brain swelling after dialysis: old urea or new osmoles?. Am J Kidney Dis 28:1131996

  • 24

    Wakim KG: The pathophysiology of the dialysis disequilibrium syndrome. Mayo Clin Proc 44:4064291969

  • 25

    Weisfelt Mden Munckhof RBouma GJMajoie CBBosch DA: [Headache and impaired consciousness due to the spontaneous intracranial hypotension syndrome.]. Ned Tijdschr Geneeskd 149:100110062005. (Dutch)

    • Search Google Scholar
    • Export Citation
  • 26

    Whiteley WAl-Shahi RMyles LLueck CJ: Spontaneous intracranial hypotension causing confusion and coma: a headache for the neurologist and the neurosurgeon. Br J Neurosurg 17:4564582003

    • Search Google Scholar
    • Export Citation
  • 27

    Zada GPezeshkian PGiannotta S: Spontaneous intracranial hypotension and immediate improvement following epidural blood patch placement demonstrated by intracranial pressure monitoring. Case report. J Neurosurg 106:108910902007

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 247 216 16
Full Text Views 172 57 1
PDF Downloads 102 25 0
EPUB Downloads 0 0 0
PubMed
Google Scholar