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What is Spontaneous Intracranial Hypotension?
Spinal anesthesia or CSF tapping could cause a lesion on dura matter, which would usually repair by itself. However, for some patients, poor wound healing of the dura may occur, resulting in CSF leakage, decrease intracranial pressure, and cause a low-pressure headache. Headaches in such cases usually occur within 1-2 days, and will generally disappear within 1 week. A headache is more likely to occur in patients who are female, with younger age or who has the history of headache. Some patients who have not received such procedure could also suffer from CSF leakage with low intracranial pressure. We call “spontaneous intracranial hypotension (SIH)”. Some patients with SIH could be traced back to traumatic experiences in the past, including coughing, lifting heavy objects, or falling accidents.

Clinical symptoms:
  1. Orthostatic headache: which is the hallmark symptom.
    1. When the patient is standing up or sitting, the brain is pulled down by gravity and stretches the blood vessels and activates painful sensation. When lying down, the headache would improve or disappear. As a result, the patient may lie whole day. 
    2. The most common feature of such headache is bilateral, non-pulsatile headache and is exacerbated when the patient hold his/her breath or forcing his/her abdominal muscle.
  2. Neck pain or stiffness, which could radiate downward and cause lower back pain.
  3. Orthostatic nausea and vomiting.
  4. Double vision: usually caused by unilateral or bilateral abducent nerve palsy. Occasionally it could be due to occulomotor or trochlear nerve palsy.
  5. Auditory symptoms: including hearing echo, tinnitus, hearing loss or impaired .
  6. Visual symptoms: including blurred vision or photophobia. 
The above symptoms are not necessary for SIH. The diagnosis has to be made by a doctor with appropriate examinations and tests. If you are used to have such symptoms, please visit the neurology clinic for further evaluation.

Treatments:
  1. Conservative treatment: most cases of SIH may resolve spontaneously within weeks or months. The treatment includes large amount of hydration or consuming beverages that contain caffeine. Hydration increases the amount of CSF and makes the brain floating in the CSF again. Some medication could be applied as well.
  2. Epidural blood patch: This is the fastest and most effective of current treatments. The doctor will draw 20-30 cc of blood from the patient and inject to around the site of CSF leakage under image guidance. The injected blood forms a clot and compresses dura and seals the leakage which prevents further CSF leakage. If the outcome is not satisfactory, a second injection of blood patch could be arranged. 
  3. Surgical repair: If two treatments (conservative treatment and epidural blood patch) are failure, surgical intervention could be considered.
Principles of Care
  1. Post-procedure care of epidural blood patch:
    1. The patient should lie flat for 4-6 hours and bed rest 24-48 hours after the procedure for increasing the probability of treatment success.
    2. Keep your spine straight, avoid deformed position.
    3. When getting out of  bed, first to lying on one side, and sit upstill with your back straight.
    4. To avoid aspirin or any kind of anticoagulant medication in order to prevent bleeding.
    5. Keep the injection site clean and dry to prevent infection. Observe if there is any sign of erythematous change, swelling, heat or pain which could indicate local infection.
    6. Notify the nurses if paralysis, stabbing pain, or new onset of headache occurs.
    7. Avoid stretching your back, lifting heavy objects and force defecation to avoid recurrent CSF leakage. 
  2. Daily care of Spontaneous Intracranial Hypotension:
    1. Stay bed rest to avoid postural headache.
    2. Avoid collisions, coughing or sneezing.
    3. If a patient has heart disease or kidney disease, please follow doctor's instructions to intake proper amount of water daily. Otherwise drink plenty of water to stay hydrated. 
    4. Caffeine-containing beverages could possibly prevent low cerebral pressure headache symptoms from increasing cerebrospinal fluid to relieve headache.
Reference
  1. Ferrante, E., Trimboli, M., & Rubino, F. (2020). Spontaneous intracranial hypotension: Review and expert opinion. Acta Neurologica Belgica, 120(1), 9-18. https://doi.org/10.1007/s13760-019-01166-8
  2. Kranz,P.G., Malinzak M.D., Amrhein T.J., Gray L. (2017). Update on the diagnosis and treatment of spontaneous intracranial hypotension. Current Pain Headache Reports, 21(8),1-8. https://doi.org/10.1007/s11916-017-0639-3
  3. Upadhyaya, P., & Ailani, J. (2019). A review of spontaneous intracranial hypotension. Current Neurology and Neuroscience Reports, 19(5), 1-6. https://doi.org/10.1007/s11910-019-0938-7
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    Taipei Veterans General Hospital 
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