Epidural Blood Patch in Subdural Hematoma Due to Spontaneous Intracranial Hypotention: A Case Report and Literature Review

Abstract

Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with variable symptoms and complications which is often misdiagnosed at initial manifestations. SIH results from spontaneous CSF leakage leading to brain sag. The typical findings on cranial MR imaging consist of subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain. Subdural hematoma may occur as a result of tearing of bridging veins and usually develop into chronic subdural hematoma. The majority of patients with SDH due to SIH have chronic DSH and, therefore, rarely present with neurological deficits. Evacuation of SDH may be performed for large SDH with ME (mass effects), or when dilated or asymmetric pupil is present. However in most cases, evacuation of the hematoma is not necessary and may result in worsened outcomes. The epidural blood patch (EBP) is a treatment of choice. Fortunately, most of these subdural hematomas can be handled with treatment directed at the underlying spinal CSF leak without the need for surgery. We report the case of 42-year-old man with the chief complaint of orthostatic headache. He was admitted to neurology ward and after imaging studies, it was found that he has bilateral subdural hematoma. Due to the lack of history of trauma, underlying disease, and coagulation disorder, and considering the imaging findings, the patient was referred to the pain department to perform an epidural blood patch. After performing the epidural blood patch, the patient's pain was relieved immediately, and during a three-month follow-up period, the epidural hematoma was completely absorbed. Spontaneous intracranial hypotension (SIH) is a highly misdiagnosed and underdiagnosed disorder and requires a high index of suspicion for diagnosis. During the last decades, a much larger number of spontaneous cases are identified. Literature is a bit confusing, with some authors recommending evacuation of subdural fluid in cases of deteriorating consciousness and few others recommending EBP first even in patients with comatose state but epidural patch is often an important part of treatment.