POST-CRANIECTOMY INTRACRANIAL HYPOTENSION - POTENTIAL IMPACT ON REHABILITATION

More aggressive neurosurgical management of intractably elevated intra cranial pressure has resulted in increased survival of severely brain injured patients, many of whom are transferred for inpatient rehabilit ation status post-craniectomy. Positional headache due to intracranial hypotension has been described in the literature, but is rarely repor ted as a complicating factor for patients receiving rehabilitation the rapies. Low cerebrospinal fluid (CSF) pressure symptoms include postur al headache, vertigo, nausea, vomiting, visual symptoms, auditory symp toms, and rarely cognitive changes. This report describes a patient wh o sustained a severe traumatic brain injury requiring craniectomy for management of increased intracranial pressure who subsequently develop ed intracranial hypotension. One month post-craniectomy, she developed postural headaches with cognitive and functional decline, which signi ficantly impaired her rehabilitation. Aggressive efforts at conservati ve management including hydration and empiric blood patch were unsucce ssful. Once the bone flap was replaced, she made rapid and dramatic fu nctional gains, with total resolution of headache. This paper hypothes izes that the mechanism of low CSF pressure after extensive craniectom y is related to loss of hydrostatic pressure following removal of the skull vault. Ln rehabilitation of severely brain injured patients with craniectomies, it is important to recognize and appropriately treat t his syndrome to avoid compromising patient care and prolonging hospita lization.