Kamal Muhammad A, Henshall David E, Hughes Mark A
Department of Neurosurgery, Royal Infirmary of Edinburgh, Edinburgh, GBR.
Deanery of Clinical Sciences, College of Medicine & Veterinary Medicine, The University of Edinburgh, Edinburgh, GBR.
Cureus. 2023 Jun 14;15(6):e40398. doi: 10.7759/cureus.40398. eCollection 2023 Jun.
Endocrine disturbances such as diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) are recognized complications of craniopharyngioma surgery, which occur due to damage to structures that produce or store antidiuretic hormone (ADH). Intracranial hypotension is a clinical syndrome that presents with headache and typical radiological features and can occur due to a leak of cerebral spinal fluid (CSF) in operations that involve the opening of the arachnoid (e.g., craniopharyngioma surgery). We describe a patient presenting with headache, radiological evidence of intracranial hypotension, and chronic DI after craniopharyngioma surgery. This occurred in the absence of evidence of a CSF leak. The headache and radiological findings resolved after the identification and treatment of DI. Intracranial hypotension may have occurred secondary to dehydration in chronic DI. A 48-year-old woman presented with progressive visual field loss due to cystic recurrence of a craniopharyngioma. She underwent redo (second) extended endoscopic transsphenoidal surgery, having previously undergone an uncomplicated debulking procedure two years prior. Her redo operation was uneventful, and her vision improved postoperatively. A lumbar drain was placed preoperatively to protect the skull base repair and was removed after 48 hours. In the initial postoperative period, she developed a clinical (polyuria) and biochemical picture consistent with DI, subsequently reverting to a SIADH, after which fluid and sodium homeostasis appeared to normalize, and she was discharged. Two months after discharge, she re-presented with new headaches eased by lying flat. Magnetic resonance imaging (MRI) brain showed bilateral convexity subdural effusions and diffuse pachymeningeal enhancement, suggesting intracranial hypotension and raising concern for postoperative CSF leak. MRI spine did not show a CSF fistula at the site of the previous lumbar drain. Transsphenoidal examination under anesthesia showed a well-healed skull base repair and no evidence of CSF leak. She concurrently reported polyuria and polydipsia. A formal water deprivation test confirmed central DI. Treatment with desmopressin improved her headache, and a follow-up MRI brain showed resolution of the previous stigmata of intracranial hypotension. This case report reminds physicians and neurosurgeons that systemic disorders (such as dehydration) can cause intracranial hypotension.
尿崩症（DI）和抗利尿激素分泌不当综合征（SIADH）等内分泌紊乱是颅咽管瘤手术公认的并发症，其发生是由于产生或储存抗利尿激素（ADH）的结构受损。颅内低压是一种临床综合征，表现为头痛和典型的影像学特征，在涉及蛛网膜开放的手术（如颅咽管瘤手术）中，可因脑脊液（CSF）漏出而发生。我们描述了一名颅咽管瘤手术后出现头痛、颅内低压的影像学证据和慢性尿崩症的患者。这发生在没有脑脊液漏证据的情况下。在识别和治疗尿崩症后，头痛和影像学表现得到缓解。颅内低压可能继发于慢性尿崩症的脱水。一名48岁女性因颅咽管瘤囊性复发出现进行性视野缺损。她接受了再次（第二次）扩大经蝶窦手术，两年前曾接受过一次无并发症的肿瘤切除手术。她的再次手术过程顺利，术后视力改善。术前放置了腰大池引流管以保护颅底修复，48小时后拔除。术后初期，她出现了与尿崩症一致的临床（多尿）和生化表现，随后转变为抗利尿激素分泌不当综合征，此后液体和钠平衡似乎恢复正常，她出院了。出院两个月后，她再次出现平躺时缓解的新头痛。脑部磁共振成像（MRI）显示双侧凸面硬膜下积液和弥漫性硬脑膜强化，提示颅内低压，并引发了对术后脑脊液漏的担忧。脊柱MRI未显示先前腰大池引流部位的脑脊液瘘。麻醉下经蝶窦检查显示颅底修复良好，无脑脊液漏证据。她同时报告有多尿和多饮。正式的禁水试验证实为中枢性尿崩症。去氨加压素治疗改善了她的头痛，随访脑部MRI显示先前颅内低压的体征消失。本病例报告提醒医生和神经外科医生，全身性疾病（如脱水）可导致颅内低压。
