Abstract
Spontaneous intracranial hypotension (SIH) is a condition caused by cerebrospinal
fluid (CSF) leakage, leading to low intracranial pressure (ICP), brain sagging, and
subdural hematoma (SDH). Management of SIH complicated by SDH presents a clinical
challenge: treating CSF leaks is performed by epidural blood patch (EBP), which elevates
ICP, while SDH management typically requires hematoma evacuation, producing a reductive
effect on ICP. Mismanagement can result in severe complications such as brain herniation
or rebound intracranial hypertension. We report two cases of SIH-associated SDH successfully
treated with simultaneous burr hole drainage and EBP, guided by continuous ICP monitoring.
Both patients presented with significant SDHs and clinical signs of SIH. At the start
of the procedure, subdural ICP was relatively low. After administration of autologous
blood, ICP rose rapidly to over 30 mm Hg, reaching levels considered dangerously high
if left unaddressed. The hematoma was evacuated without delay, and patients had no
recurrence or complications. EBP under real-time monitoring facilitated timely intraoperative
decisions and tailored responses to dynamic intracranial changes. This approach provides
a framework for individualized and safe intervention in complex dual-pathology scenarios.
Keywords cerebrospinal fluid leak - epidural blood patch - intracranial pressure monitoring
- spontaneous intracranial hypotension - subdural hematoma
