Cerebrospinal fluid leakage at the lumbar spine: A unique cause of delayed neurologic deterioration in a traumatic acute subdural hematoma patient

Keita Mayanagi; Masashi Nakatsukasa; Joji Inamasu

doi:10.4103/ajns.AJNS_185_17

Asian Journal of Neurosurgery, Inhaltsverzeichnis

CC BY-NC-ND 4.0 · Asian J Neurosurg 2019; 14(01): 219-222
DOI: 10.4103/ajns.AJNS_185_17

Case Report

Cerebrospinal fluid leakage at the lumbar spine: A unique cause of delayed neurologic deterioration in a traumatic acute subdural hematoma patient

Autor*innen

Keita Mayanagi

Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya
Masashi Nakatsukasa

Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya
Joji Inamasu

Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya

Abstract

We present a rare case of traumatic acute subdural hematoma (SDH) in which intracranial hypotension (IC) secondary to cerebrospinal fluid (CSF) leakage at the lumbar spine caused delayed neurological deterioration. A 70-year-old male sustained a head injury after ground-level fall and was brought to our institution. A brain computed tomography (CT) showed a thin acute SDH with mild brain shift, and conservative management was initiated. He exhibited neurological deterioration on the 9^th hospital day, however, and a brain CT showed a change in CT density and marked an increase in hematoma volume and brain shift. It was thought that conversion from acute to subacute SDH was associated with the deterioration, and emergency hematoma evacuation was performed. Despite the surgery, neither clinical nor radiographical improvement occurred. The lack of improvement pointed to the presence of underlying IC, and a CT myelography revealed the dural sleeve of the right L2 nerve root as the source of the CSF leakage. An epidural blood patch therapy was performed on the 12^th hospital day to seal the CSF leakage. The postprocedural course was uneventful, and the patient was discharged free of symptoms on the 20^th hospital day. Spinal CSF leakage should be considered as a cause of delayed neurological deterioration in patients with traumatic acute SDH which exhibits conversion to subacute SDH.

Key-words:

Acute subdural hematoma - cerebrospinal fluid leakage - intracranial hypotension - lumbar spine - subacute subdural hematoma

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Referenzen

References
1 Inamasu J, Saito R, Nakamura Y, Horiguchi T, Kuroshima Y, Ichikizaki K, et al. Therapeutic hypothermia for severely head-injured patients with acute subdural haematoma. J Clin Neurosci 2006;13:733-7.
2 Vega RA, Valadka AB. Natural history of acute subdural hematoma. Neurosurg Clin N Am 2017;28:247-55.
3 Inamasu J, Nakamura Y, Saito R, Kuroshima Y, Mayanagi K, Ohba S, et al. Rapid resolution of traumatic acute subdural hematoma by redistribution. Am J Emerg Med 2002;20:376-7.
4 Inamasu J, Hasegawa M, Hayashi T, Kato Y, Hirose Y. Hemispheric differences in the surgical outcomes of patients with traumatic acute subdural hematoma. J Negat Results Biomed 2014;13:10.
5 Kpelao E, Beketi KA, Moumouni AK, Doleagbenou A, Ntimon B, Egbohou P, et al. Clinical profile of subdural hematomas: Dangerousness of subdural subacute hematoma. Neurosurg Rev 2016;39:237-40.
6 Bajsarowicz P, Prakash I, Lamoureux J, Saluja RS, Feyz M, Maleki M, et al. Nonsurgical acute traumatic subdural hematoma: What is the risk? J Neurosurg 2015;123:1176-83.
7 Kim BJ, Park KJ, Park DH, Lim DJ, Kwon TH, Chung YG, et al. Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury. Acta Neurochir (Wien) 2014;156:1605-13.
8 Izumihara A, Yamashita K, Murakami T. Acute subdural hematoma requiring surgery in the subacute or chronic stage. Neurol Med Chir (Tokyo) 2013;53:323-8.
9 Inamasu J, Guiot BH. Intracranial hypotension with spinal pathology. Spine J 2006;6:591-9.
10 Inamasu J, Nakamura Y, Orii M, Saito R, Kuroshima Y, Mayanagi K, et al. Treatment of spontaneous intracranial hypotension secondary to C-2 meningeal cyst by surgical packing – Case report. Neurol Med Chir (Tokyo) 2004;44:326-30.
11 Inamasu J, Moriya S, Shibata J, Kumai T, Hirose Y. Spontaneous intracranial hypotension manifesting as a unilateral subdural hematoma with a marked midline shift. Case Rep Neurol 2015;7:71-7.
12 Beck J, Gralla J, Fung C, Ulrich CT, Schucht P, Fichtner J, et al. Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients. J Neurosurg 2014;121:1380-7.
13 Inamasu J, Nakatsukasa M. Blood patch for spontaneous intracranial hypotension caused by cerebrospinal fluid leak at C1-2. Clin Neurol Neurosurg 2007;109:716-9.
14 Kuramae T, Inamasu J, Nakagawa Y, Nakatsukasa M. Spontaneous intracranial hypotension presenting without orthostatic headache complicated by acute subdural hematoma after drainage for chronic subdural hematoma – Case report. Neurol Med Chir (Tokyo) 2011;51:518-21.
15 Pleasure SJ, Abosch A, Friedman J, Ko NU, Barbaro N, Dillon W, et al. Spontaneous intracranial hypotension resulting in stupor caused by diencephalic compression. Neurology 1998;50:1854-7.
16 Schievink WI, Jacques L. Recurrent spontaneous spinal cerebrospinal fluid leak associated with “nude nerve root” syndrome: Case report. Neurosurgery 2003;53:1216-8.
17 Watanabe A, Horikoshi T, Uchida M, Koizumi H, Yagishita T, Kinouchi H, et al. Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neuroradiol 2009;30:147-51.
18 Ohtonari T, Nishihara N, Ota T, Kobanawa S, Ota S, Danjo W, et al. Rapid reduction of syrinx associated with traumatic intracranial hypotension by direct surgery: Case report. Neurol Med Chir (Tokyo) 2009;49:66-70.
19 Cheshire WP Jr., Wharen RE Jr. Trigeminal neuralgia in a patient with spontaneous intracranial hypotension. Headache 2009;49:770-3.
20 Hasiloglu ZI, Abuzayed B, Imal AE, Cagil E, Albayram S. Spontaneous intracranial hypotension due to intradural thoracic osteophyte with superimposed disc herniation: Report of two cases. Eur Spine J 2012;21 Suppl 4:S383-6.
21 Tontisirin N, Benjhawaleemas P, Nimmaanrat S, Sathirapanya P, Laohawiriyakamol T, Tran DQ, et al. Cervical foraminal epidural blood patch for the targeted treatment of refractory cerebrospinal fluid leakage from a dural sleeve. Reg Anesth Pain Med 2018;43:205-10.