Successful treatment of spontaneous intracranial hypotension with targeted thoracic epidural patch: reversible coma with reversible corpus callosum splenium lesion

A 55-year-old man presented with spontaneous intracranial hypotension (SIH) complicated with reversible diffusion restriction in the splenium of the corpus callosum and subdural fluid collections. Cerebrospinal fluid leakage was detected in thoracic spine and the patient was treated with targeted epidural blood patch. SIH can be life threatening and result in different clinical manifestations from mild orthostatic headache to deep coma. SIH is caused by cerebrospinal fluid leakage and results mostly in orthostatic headache. It has been increasingly recognized concomitant with the improved sensitivity of imaging modalities. To our knowledge, this is the first report showing reversible diffusion restriction in the splenium of corpus callosum in SIH; however, it has been described in various disorders. Although the most common clinical manifestation is orthostatic headache, SIH presenting with confusion and coma has rarely been reported. A change in headache pattern or consciousnes should alert the physician to the possibility of development of complications, such as subdural hematoma or cerebral venous thrombosis. With the advent of MR myelography, targeted epidural blood patches may be considered as the first-line treatment, directed at the identified spinal CSF leaks. The treatment epidural blood patches, preferably delivered at the level of spinal CSF leaks can be live saving and should be reserved for intractable case.

Fig 1. sagging of the splenium of the corpus callosum, absence of suprasellar cistern and increase of the pituitary gland volume.

Fig. 2. MR myelography shows perineural root sleeve cyst.

Fig. 3. Suprasellar cistern has become visible and volume of the pituitary gland has decreased after treatment.