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Abstract Details

Trendelenburg Reversal of Coma in Spontaneous Intracranial Hypotension
Neurohospitalist
P7 - Poster Session 7 (5:00 PM-6:00 PM)
3-002
N/A
Spontaneous intracranial hypotension (SIH) is a clinical and radiological syndrome caused by spinal leakage of cerebrospinal fluid (CSF) due to a dural tear, leaking meningeal diverticulum, or CSF-venous fistula. While the hallmark clinical feature of SIH is orthostatic headache, in rare instances, life threatening complications may include altered consciousness and even coma as a result of extreme downward displacement of the midbrain and brainstem. We describe the clinical features, neuroimaging findings, management strategies, and short-term outcomes of two unique cases of severe SIH and the role of Trendelenburg position to reverse coma in these patients.
Case report.
Two women (aged 60 and 63 years) presented in coma with Glasgow Coma Scale (GCS) score of 8 (E2V2M4). Both demonstrated rapid recovery to normal mentation (GCS 15) within one hour of placement in Trendelenburg position. Pre-operative imaging was consistent with severe brain sag and associated brainstem distortion. One patient had suffered an aneurysmal subarachnoid hemorrhage (SAH), treated at an outside facility several weeks earlier, before presenting to our center with progressive deterioration in mental status. The other patient had accompanying features of bilateral subdural collections, pseudo-SAH, and effacement of the suprasellar cistern. CT myelography revealed type 1a cerebrospinal fluid leaks secondary to ventral dural tears from osteophyte complexes in each patient (at T3-T4 and T12-L1). Both patients were treated successfully with dural repair surgery and had full recovery. At one month follow up, both patients remained neurologically unimpaired.
Rapid reversal of coma to normal mentation following placement in Trendelenburg position for stabilization of SIH has rarely been reported. Given the high morbidity and mortality associated with coma in SIH, these cases serve to highlight the importance of this simple maneuver for acute management of severe SIH while awaiting definitive treatment.
Authors/Disclosures
Tony Zhang, MBChB
PRESENTER 		Dr. Zhang has nothing to disclose.
Sara Hooshmand, MD (Mayo Clinic) Dr. Hooshmand has nothing to disclose.
Nathaniel P. Rogers, Jr., MD Dr. Rogers has nothing to disclose.
David Sohutskay, MD, PhD An immediate family member of Dr. Sohutskay has received personal compensation for serving as an employee of Abbott. An immediate family member of Dr. Sohutskay has received personal compensation for serving as an employee of EBR Systems.
Michel Toledano, MD (Mayo Clinic) Dr. Toledano has nothing to disclose.
Jeremy K. Cutsforth-Gregory, MD, FAAN (Mayo Clinic) Dr. Cutsforth-Gregory has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for AAN. Dr. Cutsforth-Gregory has received publishing royalties from a publication relating to health care.
Rafid Mustafa, MD (Mayo Clinic, Department of Neurology) Dr. Mustafa has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Horizon Therapeutics. Dr. Mustafa has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for PicnicHealth. Dr. Mustafa has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Annexon Biosciences. Dr. Mustafa has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Annexon Biosciences.