Intrathecal Saline Infusion as an Effective Temporizing Measure in the Management of Spontaneous Intracranial Hypotension.

Background: Spontaneous intracranial hypotension (SIH) is a rare condition for which no optimal treatment guidelines have been determined. The most common presentation is orthostatic headaches, but patients can present with a variety of symptoms.

Case Description: We present a case of a 34-year-old man who developed progressive orthostatic headaches and bilateral subdural collections. His symptoms along with imaging of his brain and spine were consistent with SIH. Unfortunately, his symptoms continued to progress, and his level of consciousness became affected. The patient did not respond to either conservative management or epidural blood patching. As the result of his worsening condition, a lumbar drain was inserted for the intrathecal infusion of normal saline to prevent tonsillar herniation. Once the infusion was started, his level of consciousness improved. It was discovered that his cerebrospinal fluid leak was due to an osteophyte within his thoracic spine, which was eroding the dura. He underwent a costo-transversectomy with the removal of the osteophyte and repair of the dural defect. The patient had some improvement after this procedure, but he remained more somnolent than expected. On subsequent imaging, it was found that his subdural collections had increased slightly in size and it was decided to drain them. Both collections were released under high pressure, and he went on to make an excellent recovery.

Conclusions: This case demonstrates that an intrathecal saline infusion can be used as an effective temporizing measure in patients with critical symptoms of SIH and it also alerts clinicians that low-pressure subdural collections can progress to subdural collections under high pressure.