Disclosures: Chase J. Smith, DO: Nothing to disclose

Case Description: A previously healthy male, sustained a severe brain injury after helmeted motorcycle crash. The patient’s initial hospital course was complicated by hydrocephalus for which a VP shunt was placed, and prolonged awakening. The patient was admitted to an inpatient rehabilitation facility equipped to treat disorders of consciousness. The patient had persistent mild hydrocephalus on transfer and was eventually revised to a very low flow shunt. Days after shunt revision, he developed progressive vomiting, apnea and bradycardia. The patient required tracheostomy and ventilatory support for stabilization. Diffuse patchy meningeal enhancement on brain MRI was concerning for meningitis, however, cerebrospinal fluid reflected desired low pressure and negative infectious work-up. Cervical spine MRI was obtained after muscle spasms and changes in spasticity were noted, revealing venous epidural plexus engorgement, which allowed for the spectrum of symptoms to be attributed to acute overshunting with intracranial hypotension.

Setting: VA Inpatient rehabilitation unit

Patient: 28-year-old with a disorder of consciousness, 8 months after initial injury.

Assessment/Results: The patient had meningeal enhancement initially concerning for meningitis after shunt revision, as ventricle size was grossly unchanged. However, negative CSF studies and signs concerning for neurogenic shock prompted cervical imaging. Acute cervical cord venous plexus engorgement and possible transient compression were suspected, but authors were unable to definitively diagnose cervical cord injury at that time. Yet, imaging both brain and cervical spine proved necessary for intracranial hypotension diagnosis once infectious work-up was negative and classic symptoms couldn’t be reported.

Discussion: Patients with disorders of consciousness present diagnostic challenges in evaluating for acute neurologic changes, especially intracranial pathology. This patient had risk for meningitis after surgical shunt revision and negative infectious work-up. Lack of reportable symptoms of intracranial hypotension, such as headache, elicited cervical imaging which proved necessary to make the correct diagnosis.

Conclusion: Intracranial hypotension can occur, despite persistently enlarged ventricles on brain MRI.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/acute-intracranial-hypotension-with-persistent-ventriculomegaly-mimicking-meningitis-sepsis-in-a-disorders-of-consciousness-patient-a-case-report/