Intracranial Hypotension

FACTS HPI PHYSICAL EXAM IMAGING Radiographic findings

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Associated articles

Tegmen Defects (Tympani and Mastoideum)

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?)
it will classically be a low-pressure headache (i.e. worse when pressure is low, i.e. when they are sitting up —> patient feels better when lies flat, because they are leaking CSF and need all the pressure they can get)

Any facial trauma?

Any history of brain/face/ear surgery?

Any recent spinal taps? (including epidurals from childbirth or any other surgery)

any recent scuba diving (barotrauma i/s/o tegmen defect)

Any salty taste in back of mouth? Dripping sensation?

Any history of shunting?

PHYSICAL EXAM

universal exam

evaluate for rhinorrhea on chest to chin provocation

evaluate for otorrhea from both ears

evaluate for diplopia, upgaze palsy

evaluate for meningismus

IMAGING

CT thin cut:

evaluate for pneumocephalus on lung window

evaluate for anterior or middle fossa cranial defect

MRI: Evaluate for signs of intracranial hypotension

enlarged pituitary gland

pachymeningeal enhancement

subdural hygomas

tonsillar descent

brainstem sagging

A/P

Admit for observation/diagnosis, floor if non-septic/meningitic

Keep red top tubes at bedside, send beta2 if leaks from nares/ears

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 encephalocele

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:

cranial defect:

anterior skull base repair w/ ENT, diamox

spinal defect:

blood patch

CSF leak repair (operatively)