Status epilepticus in intracranial hypotension, rare complication of CSF diversion

Abstract

A relationship between seizures and intracranial pressure (ICP) has been proposed, but not clearly identified. We report two cases of status epilepticus on patients shunted for hydrocephalus. Case 1: Twenty nine year old Pakistani gentleman, presented with history of headache, diplopia and unsteadiness of gait. CT brain showed communicating hydrocephalus. He underwent VP shunt, which improved his symptoms. CSF analysis was normal. Two weeks later he presented with parkinsonism, bulbar dysfunction and encephalopathy followed by generalized seizures. Repeat CT showed diffuse cerebral edema, sagging brainstem and downward drooping splenium of the corpus callosum suggesting intracranial hypotension. He was treated with anti epileptic drugs (AED), but his EEG continued to show electrographic seizures. His VP shunt was programmed to a higher resistance level, reducing the CSF diversion rate and thus improving the intracranial hypotension. His symptoms improved and he became seizure free. EEG showed improvement in parameters. Case 2: Thirty one year old Nigerian gentleman presented with fever and altered sensorium. CT showed communicating hydrocephalus. He was diagnosed to have tuberculous meningitis based on CSF analysis including culture. He underwent VP shunt and was started on antituberculous therapy and steroids. Two months later he started having seizures refractory to multiple AEDs. CT showed features of intracranial hypotension and EEG showed electrographic seizures. Intracranial hypotension can present with varying manifestations. Seizures in a patient who has a shunt procedure should warrant a consideration of intracranial hypotension since they respond to changing CSF pressures only.