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Final Program


Final Program

1611 - Brain Sagging due to Spontaneous Intracranial Hypotension: An Underdiagnosed Cause of Disorder of Consciousness

Thursday, February 27, 2025
5:00 PM - 6:30 PM MST

    Presenting Author(s)

  • SW

    Samantha C. Wu, MD

    Resident
    Johns Hopkins University School of Medicine
    Baltimore, Maryland, United States

    • Co-Author(s)

  • DK

    Daniel Krasna, MD

    Assistant Professor
    Johns Hopkins University School of Medicine
    Baltimore, Maryland, United States

Case Diagnosis: Spontaneous intracranial hypotension

Case Description: We present an unusual case of spontaneous intracranial hypotension (SIH) in a p</span>atient who developed a disorder of consciousness (DoC) in the inpatient rehabilitation setting after thoracic laminectomy and fusion for dural defect repair. Although imaging showed brain sagging and dural enhancement, the diagnosis of SIH was delayed due to the patient’s nonspecific symptomatology. He was subsequently treated with conservative measures including Trendelenburg positioning and bed rest. His mentation ultimately returned to baseline after several weeks. 

Discussions: SIH is a potentially fatal neurologic condition caused by low intracranial pressure secondary to cerebral spinal fluid (CSF) volume disequilibrium. The hallmark of SIH is orthostatic headache. However, other symptoms associated with SIH may be nonspecific and variable, often leading to misdiagnosis and delayed treatment. Workup may involve CSF pressure measurement and MRI of the brain and spine. Imaging findings include pachymeningeal enhancement, brain sagging, and evidence of CSF leak. Due to a dearth of evidence in the efficacy of therapeutic options, there is no first-line treatment for SIH. Conservative therapy used includes bed rest, Trendelenburg positioning, hydration, and oral caffeine. Epidural blood patch and surgery are sometimes performed to treat the underlying CSF leak. 

Conclusions: SIH is potentially fatal and often misdiagnosed, which underscores the importance of studying patients with this disorder. Clinical presentations vary widely, with some patients presenting without the characteristic orthostatic headache. Chronic cases may demonstrate dementia-like syndromes while acute cases may manifest as rapid change in mental status, as observed in our patient. Acute SIH is a serious condition that can present in the inpatient rehabilitation setting and should be considered in patients who develop rapid mental status change and possess risk factors for CSF leak, such as a history of spinal surgery. Understanding the pathophysiology of this elusive disorder may facilitate early identification and timely treatment.