Objective:

N/A

Background:

Spontaneous intracranial hypotension (SIH) is a clinical and radiological syndrome caused by spinal leakage of cerebrospinal fluid (CSF) due to a dural tear, leaking meningeal diverticulum, or CSF-venous fistula. While the hallmark clinical feature of SIH is orthostatic headache, in rare instances, life threatening complications may include altered consciousness and even coma as a result of extreme downward displacement of the midbrain and brainstem. We describe the clinical features, neuroimaging findings, management strategies, and short-term outcomes of two unique cases of severe SIH and the role of Trendelenburg position to reverse coma in these patients.

Design/Methods:

Case report.

Results:

Two women (aged 60 and 63 years) presented in coma with Glasgow Coma Scale (GCS) score of 8 (E2V2M4). Both demonstrated rapid recovery to normal mentation (GCS 15) within one hour of placement in Trendelenburg position. Pre-operative imaging was consistent with severe brain sag and associated brainstem distortion. One patient had suffered an aneurysmal subarachnoid hemorrhage (SAH), treated at an outside facility several weeks earlier, before presenting to our center with progressive deterioration in mental status. The other patient had accompanying features of bilateral subdural collections, pseudo-SAH, and effacement of the suprasellar cistern. CT myelography revealed type 1a cerebrospinal fluid leaks secondary to ventral dural tears from osteophyte complexes in each patient (at T3-T4 and T12-L1). Both patients were treated successfully with dural repair surgery and had full recovery. At one month follow up, both patients remained neurologically unimpaired.

Conclusions:

Rapid reversal of coma to normal mentation following placement in Trendelenburg position for stabilization of SIH has rarely been reported. Given the high morbidity and mortality associated with coma in SIH, these cases serve to highlight the importance of this simple maneuver for acute management of severe SIH while awaiting definitive treatment.