Benign intracranial hypotension: An unusual presentation with bilateral subdural hematoma and successful management with epidural blood patch

Introduction: Benign intracranial hypotension is characterized by orthostatic headache, nausea, vomiting, tinnitus, vertigo, diplopia and wide variety of symptoms. It is mainly because of CSF leakage which can be caused by trauma, epidural analgesia, dural puncture but in most of the cases it is spontaneous. Rarerly patient will present with subdural hematoma. In that cases proper history, meticulous investigations, high index of suspicion and appropriate management will be required. Here we are presenting a case who presented with bilateral subdural hematoma because of benign intracranial hypotension managed successfully with epidural blood patch and evacuation of hematoma. Case Summary: Forty year male patient presented to casualty with orthostatic headache, vomiting since 1 month and altered sensorium, giddiness since 2 days. There was no history of trauma. MRI brain showed prominent subdural hematoma in the late subacute stage in right frontotemperoparietal region with mass effect associated with thin subdural hematoma on left side. There was mild inferior displacement of floor of third ventricle which was draping along the dorsum sellea. There was associated effacement of prepontine cistern. There was mild compression and distortion of bilateral cerebral peduncles. These findings were suspicious of benign intracranial hypotension, but other possibility of these features being secondary to mass effect from subdural collections was cannot be entirely ruled out. Keeping in mind subdural hematomas may be because of benign intracranial hypotension we adviced MR myelogram of spine to look for CSF leaks. MR myelogram showed thin layer of epidural fluid in lumbar spine extending from L1 to L5. Which was indirect evidence of CSF leak and collection of CSF into epidural space but was not confirmatory. As patient condition was deteriorating we planned for evacuation of SDH under GA. But before that we planned to put epidural blood. Before inducing the patient under fluoroscopy guidance in lateral position 25 cc of autologous blood was injected in T11-T12 epidural space. Then under standard general anaesthesia only left sided SDH was evacuated which was causing mass effect. Postoperatively patient nursed in supine position for 5 days and gradually reverse trendelburg position was given. Again at 45 degree propped up position patient started having headache, vomiting. Repeat epidural blood patch was given at T6-T8 position. Patient recovered well post procedure and there were no symptoms after 3 days even at erect posture. Conclusion: Benign intracranial hypotension can present with wide variety of symptoms and always have to be kept in mind. High index of suspicion, proper history and investigations, sealing of CSF leak with epidural blood patch will help the patient.