Posttraumatic cerebrospinal fluid hypertension and hypotension.

A 14-year-old girl fell off a truck, striking her head. She lost consciousness for 7 minutes. Results of initial evaluation and computed tomography (CT) of the head appeared to be unremarkable on the day of her injury. Three days later, she presented with symptoms of increased ICP including persistent headaches, vomiting, and pulsatile tinnitus, as well as decreased hearing on the right. Head CT and a CT angiogram showed a complex right mastoid petrous fracture and a right sigmoid sinus thrombosis with extravasation of blood from the right sigmoid sinus into the middle ear (Figure, A). The patient’s condition remained stable throughout her 5-day hospital stay, without visual complaints or worsening intracranial hypertension. A repeat CT angiogram demonstrated resolution of active extravasation from the right sigmoid sinus, without change in the degree of thrombosis. Two weeks later the patient developed increased head swelling, worsening of her headaches (which were relieved when she was lying down), and horizontal binocular diplopia. On examination, she had diffuse head enlargement with a fluctuant fluid wave. A CT scan showed diffuse subgaleal fluid from one temporalis to the other, suggestive of cerebrospinal fluid (CSF) (Figure, B). Neuro-ophthalmologic examination showed decreased abduction in both eyes with a comitant 12– prism diopter esotropia consistent with divergence insufficiency. There was no papilledema. The findings of divergence insufficiency in this setting suggested abnormal ICP, either increased or decreased. Therefore, to investigate the possibility of persistent venous sinus thrombosis as a cause of elevated ICP, follow-up CT angiography was performed, which demonstrated resolution of the right sigmoid sinus thrombosis. No measurement of the CSF pressure was obtained, so as not to worsen her symptoms presumed to be related to CSF hypotension. Her diplopia fully resolved within 2 weeks and results of follow-up examination were normal.