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CC BY 4.0 · Arq Neuropsiquiatr 2023; 81(02): 128-133
DOI: 10.1055/s-0042-1758752
Original Article

Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center

Hipotensão intracraniana espontânea: de trombose venosa cerebral ao tratamento cirúrgico: uma série de casos de um centro terciário de saúde brasileiro
Daniel Gabay Moreira 
1   Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
,
Evandro Penteado Villar Félix 
1   Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
,
Franz Jooji Onishi 
2   Universidade Federal de São Paulo, Departamento de Neurocirurgia, São Paulo SP, Brazil.
,
Henrique Ballalai Ferraz 
1   Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
,
Tácio Luis Cavalcante Coradine 
1   Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
,
Vinícius Lopes Braga 
1   Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
,
Enedina Maria Lobato de Oliveira 
1   Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
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Abstract

Background Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT).

Objective To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward.

Methods Review of the medical files of three patients and description of clinical and surgical outcomes.

Results Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with laminoplasty. Both of them had uneventful recovery and remission in surgery follow-up.

Conclusion The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.

RESUMO

Antecedentes Hipotensão intracraniana espontânea (HIE) é uma causa secundária de cefaleia e uma doença subdiagnosticada. A apresentação clínica pode ser muito variável. Tipicamente, se apresenta com queixas isoladas de cefaleia ortostática clássica, porém pode evoluir com complicações significativas como trombose venosa cerebral (TVC).

Objetivo Relatar 3 casos de diagnóstico de hipotensão intracraniana espontânea manejados em uma enfermaria de neurologia de nível terciário.

Métodos Revisão dos prontuários de três pacientes e descrição dos resultados clínicos e cirúrgicos.

Resultados Três pacientes do sexo feminino com média de idade de 25.6 ± 10.0 anos. As pacientes apresentavam cefaleia ortostática e uma delas apresentou sonolência e diplopia devido a TVC. A ressonância magnética (RM) do encéfalo varia de achados normais até achados clássicos de HIE como realce paquimeníngeo e deslocamento inferior das tonsilas cerebelares. A RM da coluna mostrou coleções anormais de líquido epidural em todos os casos e a mielografia por tomografia computadorizada (TC) foi capaz de determinar fístula liquórica identificável em apenas uma paciente. Uma paciente recebeu abordagem conservadora e as outras duas foram submetidas a cirurgia aberta com laminoplastia. Ambas tiveram recuperação e remissão sem intercorrências no seguimento cirúrgico.

Conclusão O diagnóstico e manejo da hipotensão intracraniana ainda são desafios na prática neurológica. Destacamos no presente estudo casos graves, complicação com TVC e bons resultados com tratamento neurocirúrgico.

Keywords

Intracranial Hypotension - Hospitalization - Headache - Neurosurgical Procedures - Venous Thrombosis

Palavras-chave

Hipotensão Intracraniana - Hospitalização - Cefaleia - Procedimentos Neurocirúrgicos - Trombose Venosa

Authors' Contributions

DGM: had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis; DGM, VLB, EMLO: contributed to the study conception and design, data acquisition, analysis and interpretation, and critical revision of the manuscript for important intellectual content; EPVF, HBF: contributed to the critical revision of the manuscript for important intellectual content; FJO: contributed to the study conception, design, and critical revision of the manuscript for important intellectual content; TLCC: contributed to the study conception, design, and acquisition of data. All authors and contributors have agreed to conditions noted on the Authorship Agreement Form.




Publication History

Received: 29 March 2022

Accepted: 24 May 2022

Article published online:
02 March 2023

© 2023. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

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