From the Departments of Neurosurgery (W.I.S., S.J.-P.) and Imaging (M.M.M., F.G.M.), Cedars-Sinai Medical Center, Los Angeles; and Department of Public Health Services (M.N.), University of California, Davis.
Neurology. 2018 May 8;90(19):e1638-e1645. doi: 10.1212/WNL.0000000000005477. Epub 2018 Apr 13.
To review our experience with patients with spontaneous intracranial hypotension (SIH) and coma because, although disorders of consciousness may complicate SIH, no comprehensive study of such patients has been reported.
Using a prospectively maintained registry, we identified all patients with SIH in whom coma developed. Patients or their caregivers/families were contacted for follow-up. Patients were compared to a cohort of patients with SIH without coma.
The mean age of the 12 men and 3 women with SIH was 56.2 years (range 34-72 years) at the time of onset of coma. In one-third of patients, coma developed after craniotomy for subdural hematomas or for an unrelated intracranial pathology. Imaging showed brain sagging, including bilateral temporal lobe herniation, in all 15 patients and brainstem edema in 8 patients (53%). Overall, coma was reversible in 7 of 15 patients treated with epidural blood patches, in 2 of 4 treated with percutaneous glue injections, and in 6 of 6 treated surgically. Only 1 patient had residual neurologic deficit related to coma (Glasgow Outcome Scale score 4 [moderate disability]). Compared to patients with SIH without coma (n = 568), those with coma were older, more often were male, and more often underwent surgery.
Coma in SIH is rare, reversible, and invariably associated with brain sagging. Coma due to SIH may be refractory to the usual percutaneous procedures, and surgical closure of the CSF leak may be required to regain consciousness.
回顾我们在自发性颅内低血压（SIH）合并昏迷患者中的经验，因为尽管意识障碍可能使 SIH 复杂化，但目前尚无此类患者的综合研究报告。
我们使用前瞻性维护的登记处，确定了所有发生昏迷的 SIH 患者。联系患者或其护理者/家属进行随访。将患者与无昏迷的 SIH 患者队列进行比较。
12 名男性和 3 名女性 SIH 患者的平均年龄为 56.2 岁（发病时 34-72 岁）。在三分之一的患者中，昏迷发生在硬膜下血肿或与颅内无关的病变开颅术后。所有 15 例患者均出现脑下垂，包括双侧颞叶疝，8 例（53%）患者出现脑干水肿。在接受硬膜外血贴治疗的 15 例患者中，7 例患者的昏迷得到逆转，4 例接受经皮胶注射治疗的患者中有 2 例，6 例接受手术治疗的患者中均有 6 例得到逆转。只有 1 例患者因昏迷而遗留神经功能缺损（格拉斯哥结局量表评分为 4[中度残疾]）。与无昏迷的 SIH 患者（n=568）相比，昏迷患者年龄更大，更常为男性，更常接受手术治疗。
SIH 中的昏迷罕见，是可逆的，且始终与脑下垂有关。SIH 引起的昏迷可能对常规经皮治疗有抗药性，可能需要手术闭合脑脊液漏以恢复意识。
