Spontaneous Intracranial Hypotension Resulting in Coma

This case expands our knowledge of the spectrum of manifestations of spontaneous intracranial hypotension. A 42-year-old man was seen for a third neurolog-ical opinion for obtundation. He presented with a 1-month history of new-onset, daily, intense, right-sided headaches (information about postural precipitation is not available). A magnetic resonance imaging (MRI) scan of the brain showed diffuse meningeal enhancement. A cervical MRI showed only bulging disks. A lumbar puncture 2 days after admission to the hospital was performed without measurement of the opening pressure. The cerebrospinal fluid (CSF) revealed a glucose of 47 mg/dL, a protein of 112 mg/dL with 10 white cells (5 lymphocytes), and 650 red blood cells. The CSF cryptococcal antigen and cultures were negative. Testing for human immunodeficiency virus (HIV) was negative. A cerebral arteriogram was negative. A meningeal biopsy showed acute and chronic inflammation but no evidence of neoplasm, sarcoid, or infection. A second lumbar puncture 10 days after the first produced an opening pressure too low to measure. There were 63 white cells (61% lymphocytes), a glucose of 58 mg/dL, and a protein of 88 mg/dL. The CSF Venereal Disease Research Laboratory (VDRL) test was nonreactive. On admission he was alert, and the neurologic examination was normal. Over the next several days, he was intermittently lethargic. Over the following 5 days, he became increasingly lethargic and stopped following commands. He was intubated because of aspiration pneumonia, but the blood gases were satisfactory. When I saw him 4 days later, he was intu-bated, his eyes were closed, and he did not follow commands. Oculocephalics appeared intact. The pupils were 3 mm and reactive to light. He withdrew all extremities to painful stimuli. Plantars were extensor bilaterally. A repeat MRI scan of the brain revealed small, bilateral, subdural fluid collections over the hemispheres , cerebellar tonsils below the foramen mag-num, and decreased fluid in the suprasellar and chias-matic cisterns. An MRI scan of the cervical, thoracic, and lumbar spine showed no evidence of a CSF leak. The initial MRI scan of the brain had been sent for another opinion to a neuroradiologist in San Fran-cisco who conferred with Dr. Robert Fishman. Dr. Fishman suggested instillation of a large-volume, lum-bar, epidural blood patch, and this subsequently was performed with 50 mL of autologous blood and the patient in the Trendelenburg position. Within 1 day of the blood patch, the patient was awake but confused. Examination showed a pupil-sparing …