Spontaneous Intracranial hypotension (SIH) currently preferred to be described as spontaneous spinal CSF leak is a disorder which is associated with orthostatic headaches, neck stiffness, tinnitus, but rarely can present with a coma.

50 yr. old woman with no history of alcoholism and taking no anti-thrombotic medications presents with sub-acute onset of headaches and found to have non traumatic acute on chronic bilateral subdural hematomas (SDH). She improved clinically after craniotomy and then worsened with sudden onset of right upper extremity weakness, coma and decerebrate posturing. EEG did not reveal seizures. Repeat CT head showed stable subdural hematomas. Due to the comatose presentation and increased white count, CSF studies were performed which resulted as normal. We noticed that patient was not on any anesthesia or sedating medication which can contribute to the coma. Clinical findings of cranial nerve palsies present during sitting posture improved with supine positioning. She had positive response to noxious stimulus in supine posture only. MRI Brain revealed diffuse dural, reticular system and pituitary enhancement, in addition to sagging brain stem with trans-tentorial herniation concerning for intracranial hypotension.