ANDRE VAZ 1, Pietro Bosquirolli Maffezzolli 2
Resumo
Secondary intracranial hypotension due to cerebrospinal fluid overdrainage.Dados do caso
Feminino 39 anos
Palavras chaves
Cefaleia, Hipotensão Intracraniana, Derrame Subdural
Histórico Clínico
A 39-year-old woman with thrombophilia developed a sigmoid sinus thrombosis that progressed to intracranial hypertension. A lumboperitoneal shunt was performed and, on the 6th postoperative day, the patient developed a headache with worsening in orthostasis and improvement after shunt valve closure.
Achados Radiológicos
Magnetic resonance imaging (MRI) depicted pachymeningeal enhancement, brain "sagging", pituitary enlargement, bilateral subdural hygroma, venous sinus engorgement and reduced ventricular size (Figure 2).
Discussão
Intracranial hypotension consists of an underdiagnosed pathology related to a cerebrospinal fluid (CSF) leak resulting in a compensatory intracranial increase in extracellular fluid and blood [1-3]. The typical symptom is headache with worsening in orthostasis, reduction in decubitus and without improvement with analgesia [1,2]. Imaging can be normal in up to 28% of cases [1,2], however the main findings consist of: cerebrospinal fluid (CSF) leak or extratecal CSF (characterized by collections in the subdural and spinal epidural spaces, spinal meningeal diverticula and CSF leak into soft tissues [1-5]), diffuse paquimeningeal enhancement [1,2,5,6], brain "sagging" (characterized by obliteration of the periquiasmatic and pre-pontine cisterns, inferiorization of the cerebellar tonsils, the optic chiasm and the mesencephalic aqueduct, flattening of the optic chiasma and overall reduction of the encephalic subarachnoid spaces [1,2,4-6]), enlarged pituitary gland (normal height up to 4.2 to 4.8 mm in women and 3.5 mm in men and considered increased when height > 1.5 times the expected [5]), neurohypophysis hematoma [5], sinus venous engorgement [5,6] and spinal epidural venous plexus engorgement [4] and reduced ventricular dimensions [4].
Lista de Diferenciais
Diagnóstico
Aprendizado
Regular pachymeningeal enhancement, brain "sagging", pituitary enlargement, dural venous sinus engorgement and reduced ventricular size characterizes intracranial hypotension.
Referências
Imagens
Figura 1. Sagittal post contrast T1-weighted sequence (A) and coronal T1-weighted sequence performed before the lumboperitoneal shunt.
Figura 2. Axial FLAIR (A), sagittal (B and C) and coronal (D) post contrast T1-weighted sequence performed after 6 days of the lumboperitoneal shunt depicting [1] pachymeningeal enhancement, brain "sagging" ([2] reduction of the mamillopontine distance, [3] obliteration of the convexity sulci, [4] obliteration of the periquiasmatic and [5] pre-pontine cisterns, [6] inferiorization of the cerebellar tonsils, [7] pituitary enlargement), [8] bilateral subdural hygroma, [9] venous sinus engorgement and [10] reduced ventricular size.
Vídeos
Artigo recebido em quarta-feira, 27 de maio de 2020
Artigo aprovado em sábado, 1 de agosto de 2020