PMC4427154_01
CT scans of the brain. An initial scan showed a chronic subdural hematoma with a marked midline shift (a). A scan obtained a day after hematoma evacuation showed the lack of reversal of the midline shift (b). A third CT scan obtained 4 days after surgery showed a worsening of the midline shift and the accumulation of subdural hematoma (c).
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F1
A brain CT revealed a right chronic subdural hematoma with a marked right-to-left midline shift (fig. 1a). No brain swelling was observed after dural opening and hematoma evacuation, and no chronological improvement in the degree of the midline shift was seen on her postoperative CT scan (fig. 1b). She was then referred to our institution; a third CT scan obtained immediately before her transfer showed a worsening of the midline shift and an increase in her subdural hematoma (fig. 1c).
An MRI of the brain on admission. An axial T1-weighted image with gadolinium showed a marked pachymeningeal enhancement, establishing the diagnosis of a spontaneous intracranial hypotension (a). A sagittal T2-weighted image showed a marked downward displacement of the cerebellar tonsils (b). At 30 days after blood patch therapy, an axial T1-weighted image with gadolinium showed a resolution of the pachymeningeal enhancement (c). A sagittal T2-weighted image showed the return of the cerebellar tonsils to the original position (d).
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F2
T1-weighted image (fig. 2a) together with the downward displacement of the cerebellar tonsil on the sagittal T2-weighted image (fig. 2b), verified the diagnosis of SIH. The brainstem was severely squeezed between the retro-odontoid mass and the posterior edge of the foramen magnum (fig. 2b). A brain MRI obtained 30 days after the blood patch therapy revealed the disappearance of contrast enhancement, subdural hematoma (fig. 2c) and the return of the brainstem to the normal position (fig. 2d).
A CT myelography before blood patch therapy showed massive leakage of the contrast medium in the entire thoracic epidural space on sagittal view (a). A leak of the contrast medium was also confirmed with the axial view (b, at the T9 level). An arrow shows a layer of the spinal dura. At 2 weeks after the blood patch therapy, no leakage of contrast medium in the epidural space was observed (c, sagittal view/d, axial view at T9 level).
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F3
A CT myelography revealed a massive CSF leakage over the entire thoracic epidural space (fig. 3a, b). A repeat CT myelography obtained 14 days after the blood patch therapy revealed no CSF leakage in the thoracic epidural space (fig. 3c, d), and she was discharged free of symptoms 20 days after the admission to our institution.