A case of subarachnoid hemorrhage associated with spontaneous intracranial hypotension

Cerebrospinal fluid (CSF) leakage has recently been documented in most patients, as the main cause of spontaneous intracranial hypotension (SIH). No cases of SIH accompanying an episode of subarachnoid hemorrhage (SAH) has yet been reported and, to the best of our knowledge, this is the first report of a patient, who developed SAH during his clinical course of SIH. SAH was cured completely by surgical intervention. A 57-year-old man, with a history of a sustained postural headache, suffered the sudden onset of severe nuchal pain. SAH in the basal cistern, together with the finding of bilateral subdural fluid retention were verified by CT. Angiogram showed no vascular abnormalities of cerebral or cervical vessels. Gd-enhanced Magnetic Resonance Imaging (MRI) disclosed diffuse meningeal enhancement. RI cisternogram and CT-myelogram (CTM) suggested that the region of CSF leakage should be in the retrospinal area at the level of C1-2. Because orthostatic headache failed to resolve even with 3 weeks of bed rest, surgical intervention was successfully carried out to seal the site of CSF leakage with the use of a fascia and fibrin glue. We have speculated that the etiology of SAH might have been a secondary rupture of congestive intracranial veins, such as basilar plexus or bridging veins, induced by a decrease of intracranial CSF pressure.