Intracranial Hypotension Syndrome after Lumbar Drainage in Skull Base Surgery: Diagnosis and Correct Management

Abstract

Lumbar drainage is commonly used in skull base surgery; however, very few cases of intracranial hypotension syndrome are reported to be caused by this procedure. We present a clinical case of lumbar drainage–assisted orbital and optic canal decompression surgery for a recurrent voluminous spheno-orbital meningioma, together with a literature review. A 49-year-old woman became confused and drowsy on postoperative day 3, after initially experiencing neurologic stability. Computed tomography (CT) scan of the head showed extradural frontotemporal fluid collection with moderate right to left midline shift. Magnetic resonance imaging (MRI) of the brain showed signs of intracranial hypotension, such as brain sagging and diffuse dural contrast enhancement. Conservative treatment with bed rest, aggressive hydration, steroids, and aminophylline led to progressive neurologic improvement. A systematic literature review was also performed, and previous reported cases were analyzed. Overall, neurosurgeons must be aware of the lumbar drainage–induced hypotension syndrome in skull base surgeries, because immediate diagnosis is essential for therapeutic decision-making. In this setting, conservative management is the first-line treatment as surgery may lead to severe complications.

Keywords

intracranial hypotension syndrome - lumbar drainage - skull base surgery - case report - literature review

Publication History

Received: 09 April 2022

Accepted: 01 September 2022

Article published online:
01 June 2023

• References

• 1 Giese H, Meyer J, Unterberg A, Beynon C. Preoperative lumbar drainage placement for surgical cranioplasty. J Clin Neurosci 2018; 52: 88-91
• 2 Wu C, Guan D, Ren M. et al. Aminophylline for treatment of postdural puncture headache: a randomized clinical trial. Neurology 2018; 90 (17) e1523-e1529
• 3 Urbach H. Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy. Curr Opin Neurol 2014; 27 (04) 414-424
• 4 D'Antona L, Jaime Merchan MA, Vassiliou A. et al. Clinical presentation, investigation findings, and treatment outcomes of spontaneous intracranial hypotension syndrome: a systematic review and meta-analysis. JAMA Neurol 2021; 78 (03) 329-337
• 5 Li G, Zhu X, Zhang Y, Zhao J, Han Z, Hou K. Cranial nerve palsy secondary to cerebrospinal fluid diversion. Clin Neurol Neurosurg 2016; 143: 19-26
• 6 Lybecker H, Møller JT, May O, Nielsen HK. Incidence and prediction of postdural puncture headache. A prospective study of 1021 spinal anesthesias. Anesth Analg 1990; 70 (04) 389-394
• 7 Amorim JA, Gomes de Barros MV, Valença MM. Post-dural (post-lumbar) puncture headache: risk factors and clinical features. Cephalalgia 2012; 32 (12) 916-923
• 8 Vandam LD, Dripps RD. Long-term follow-up of patients who received 10,098 spinal anesthetics; syndrome of decreased intracranial pressure (headache and ocular and auditory difficulties). J Am Med Assoc 1956; 161 (07) 586-591
• 9 Delmotte K, Demaerel P, Demeestere J. MRI findings in liquor hypotension syndrome. Acta Neurol Belg 2019; 119 (02) 273-274
• 10 Kranz PG, Gray L, Malinzak MD, Amrhein TJ. Spontaneous intracranial hypotension: pathogenesis, diagnosis, and treatment. Neuroimaging Clin N Am 2019; 29 (04) 581-594
• 11 Mathew L, Komotar R. Epidural blood patch for severe postoperative intracranial hypotension. J Neurosurg Anesthesiol 2008; 20 (01) 49-52
• 12 Turner CR, Losasso TJ, Muzzi DA, Weglinski MR. Brain relaxation and cerebrospinal fluid pressure during craniotomy for resection of supratentorial mass lesions. J Neurosurg Anesthesiol 1996; 8 (02) 126-132
• 13 Komotar RJ, Ransom ER, Mocco J. et al. Critical postcraniotomy cerebrospinal fluid hypovolemia: risk factors and outcome analysis. Neurosurgery 2006; 59 (02) 284-290 , discussion 284–290
• 14 Kawahara I, Tsutsumi K, Matsunaga Y. et al. Early awareness of cerebrospinal fluid hypovolemia after craniotomy for microsurgical aneurysmal clipping. Acta Neurochir (Wien) 2013; 155 (08) 1543-1548
• 15 Telischi FF, Landy H, Balkany TJ. Reducing temporal lobe retraction with the middle fossa approach using a lumbar drain. Laryngoscope 1995; 105 (02) 219-220
• 16 Viswanathan A, Whitehead WE, Luerssen TG, Jea A. Use of lumbar drainage of cerebrospinal fluid for brain relaxation in occipital lobe approaches in children: technical note. Surg Neurol 2009; 71 (06) 681-684 , discussion 684
• 17 Guido LJ, Patterson Jr RH. Focal neurological deficits secondary to intraoperative CSF drainage: successful resolution with an epidural blood patch. Report of two cases. J Neurosurg 1976; 45 (03) 348-351
• 18 Grady RE, Horlocker TT, Brown RD, Maxson PM, Schroeder DR. Mayo Perioperative Outcomes Group. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Anesth Analg 1999; 88 (02) 388-392
• 19 Samadani U, Huang JH, Baranov D, Zager EL, Grady MS. Intracranial hypotension after intraoperative lumbar cerebrospinal fluid drainage. Neurosurgery 2003; 52 (01) 148-151 , discussion 151–152
• 20 Kim YS, Kim SH, Jung SH, Kim TS, Joo SP. Brain stem herniation secondary to cerebrospinal fluid drainage in ruptured aneurysm surgery: a case report. Springerplus 2016; 5: 247
• 21 Tanweer O, Kalhorn SP, Snell JT. et al. Epidural blood patch performed for severe intracranial hypotension following lumbar cerebrospinal fluid drainage for intracranial aneurysm surgery. Retrospective series and literature review. J Cerebrovasc Endovasc Neurosurg 2015; 17 (04) 318-323
• 22 Alaraj A, Munson T, Herrera SR, Aletich V, Charbel FT, Amin-Hanjani S. Angiographic features of “brain sag.”. J Neurosurg 2011; 115 (03) 586-591
• 23 Motoyama Y, Nakajima T, Takamura Y. et al. Risk of brain herniation after craniotomy with lumbar spinal drainage: a propensity score analysis. J Neurosurg 2018; 130 (05) 1710-1720
• 24 Lane BC, Scranton R, Cohen-Gadol AA. Risk of brain herniation after craniotomy with preoperative lumbar spinal drainage: a single-surgeon experience of 365 patients among 3000 major cranial cases. Oper Neurosurg (Hagerstown) 2021; 20 (02) E77-E82
• 25 Loya JJ, Mindea SA, Yu H, Venkatasubramanian C, Chang SD, Burns TC. Intracranial hypotension producing reversible coma: a systematic review, including three new cases. J Neurosurg 2012; 117 (03) 615-628
• 26 Zwagerman NT, Wang EW, Shin SS. et al. Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 2018; 131 (04) 1172-1178
• 27 Liang B, Shetty SR, Omay SB. et al. Predictors and incidence of orthostatic headache associated with lumbar drain placement following endoscopic endonasal skull base surgery. Acta Neurochir (Wien) 2017; 159 (08) 1379-1385
• 28 Francel PC, Persing JA, Cantrell RW, Levine PA, Newman SA. Neurological deterioration after lumbar cerebrospinal fluid drainage. J Craniofac Surg 1992; 3 (03) 145-148
• 29 Hirono S, Kawauchi D, Higuchi Y. et al. Life-threatening intracranial hypotension after skull base surgery with lumbar drainage. J Neurol Surg Rep 2015; 76 (01) e83-e86
• 30 Hulou MM, Abd-El-Barr MM, Gormley WB, Zamani AA, Dunn IF, Al-Mefty O. The frequency and severity of intracranial hypotension post-intraoperative lumbar drainage using a Tuohy needle and the traditional needle. Br J Neurosurg 2016; 30 (04) 438-443
• 31 Bond KM, Benson JC, Cutsforth-Gregory JK, Kim DK, Diehn FE, Carr CM. Spontaneous intracranial hypotension: atypical radiologic appearances, imaging mimickers, and clinical look-alikes. AJNR Am J Neuroradiol 2020; 41 (08) 1339-1347
• 32 Hou K, Zhu X, Zhang Y. et al. Early post-operative cerebrospinal fluid hypovolemia: report of 7 cases. Exp Ther Med 2018; 15 (06) 5119-5124
• 33 Graff-Radford SB, Schievink WI. High-pressure headaches, low-pressure syndromes, and CSF leaks: diagnosis and management. Headache 2014; 54 (02) 394-401
• 34 Monks TJ, Smith RL, Caldwell J. A metabolic and pharmacokinetic comparison of theophylline and aminophylline (theophylline ethylenediamine). J Pharm Pharmacol 1981; 33 (02) 93-97
• 35 Cannizzaro D, Tropeano MP, Milani D. et al. Microsurgical versus endoscopic trans-sphenoidal approaches for clivus chordoma: a pooled and meta-analysis. Neurosurg Rev 2021; 44 (03) 1217-1225