Intracranial Hypotension

FACTS

 

HPI

Universal ROS: HA, nausea, vomiting, seizures, falls, trauma, visual changes (blurry/double vision)
  • evaluate specifics of headache - location, is it postural (improved with recumbency?)
Any facial trauma?
Any recent spinal taps? (including epidurals from childbirth)
Any salty taste in back of mouth? Dripping sensation?
Any history of shunting?

PHYSICAL EXAM

evaluate for rhinorrhea on chest to chin provocation
evaluate for otorrhea from both ears
evaluate for diplopia, upgaze palsy
evaluate for meningismus

IMAGING

Evaluate for signs of intracranial hypotension
  • enlarged pituitary gland
  • pachymeningeal enhancement
  • subdural hygomas
  • tonsillar descent
  • brainstem sagging
A/P
Evaluate for anterior skull base leak
ENT c/s for scoping nose/ears
CTH IGS / CT Max face to evaluate for skull base defects
MRI Skull base w/wo to evaluate for encephaloceles
Evaluate for spinal leak
CT myelogram
Could also consider MRI CTL spine w/wo contrast including FIESTA sequences to eval for leak --> may show enlarged venous plexus, subdural collections, pachymeningeal enhancement, nerve root sleeve thickening, CSF leakage site
 
Definitive treatment based on etiology: 
blood patch
CSF leak repair (operatively)
anterior skull base repair w/ ENT, diamox

Radiographic findings

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Figure 1: Enlarged pituitary gland. Physiology of this finding: low pressure allows pituitary tissue to expand and fill the suprasellar cistern.
Figure 2: pachymeningeal enhancement 
Figure 2: pachymeningeal enhancement