PMC9556835_01
Timeline of the disease development and progression, signs and symptoms, diagnostic workup and findings, surgical treatment, and 3-months follow-up. BSD, brain sagging dementia; ICP, intracranial pressure; EVD, external ventricular drain; GCS, Glasgow Coma Scale; VP-shunt, ventriculoperitoneal shunt.
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F1
He then suffered a "new type of headache" that was worse in standing position (Figure 1).
MRI findings of brain sagging dementia in this case. (A) The preoperative MRI in sagittal, axial and coronal planes show typical signs of intracranial hypotension, including sagging brainstem (SB) toward the clival bone, downward tonsillar (T) ectopy, smaller ponto-mesencephalic angle (indicated by an asterisk), enhancement of the dura (D), rounding of the cross-section of the dural venous sinus (S) indicative of dural venous engorgement, transtentorial herniation (H), and reduced space for the mesencephalon (M). (B) The postoperative MRI in sagittal and axial planes demonstrate reversal of the MRI signs of brain sagging. (C) The cranial bone (CB) with a defect (indicated by an arrow), as presented during surgical exploration.
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F2
During his stay in our department, imaging showed severe brain sagging with subsequent CSF flow obstruction through the cerebral aqueduct (Figure 2). A cranial defect corresponding to his childhood head trauma was evident during the surgical exploration (Figure 2).
Intracranial pressure was measured from a Codman ICP sensor placed in the right frontal lobe. (A) The left window presents the trend plots of mean ICP (MeanP, light green) and mean ICP wave amplitude (MeanWave AMP, darker green). To the right is indicated the average values for the trend plots: Mean ICP - 8.7 mmHg, Mean Wave AMP (amplitude) 2.6 mmHg, Mean wave RT (Rise time) 0.22 s, Mean Wave RT Coeff (Rise time coefficient) 12.8 mmHg/s. Total 18,237 6-s windows were analyzed, wherein 13,157 were of acceptable quality for analysis (acceptance 72%). (B) The left window presents another trend plot of mean ICP (MeanP, light green) and of mean ICP wave amplitude (MeanWave AMP, darker green). To the right is indicated the average values for these trend plots: Mean ICP - 1.0 mmHg, Mean Wave AMP (amplitude) 3.0 mmHg, Mean wave RT (Rise time) 0.21 s, Mean Wave RT Coeff (Rise time coefficient) 16.0 mmHg/s. Total 20,001 6-s windows were analyzed, wherein 15,725 were of acceptable quality for analysis (acceptance 79%). (C) One 6-s time window is shown with five single pressure waves identified by their diastolic minimum and systolic maximum pressures. For this particular 6-s time window, parameters were: Mean ICP - 1.1 mmHg, Mean Wave AMP (amplitude) 3.4 mmHg, Mean wave RT (Rise time) 0.35 s, Mean Wave RT Coeff (Rise time coefficient) 9.5 mmHg/s. Image: Sensometrics RD Software (dPCom AS, Oslo, Norway).
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F3
CSF leak was identified. Continuous intracranial pressure (ICP) monitoring revealed severe intracranial hypotension with ICP scores < - 10 mmHg (Figure 3).