Working Diagnosis:
Intracranial hypotension from post-concussive CSF leak complicated by subdural hematoma

Treatment:
The patient was admitted to the neurosurgical service. He initially underwent a fluoroscopic-guided autologous blood patch, which was unsuccessful. He eventually underwent open surgery to repair the tear in his dura, with subsequent resolution of his symptoms. On repeat imaging, there were no signs of persistent CSF leak, and the subdural hematoma resorbed.

Outcome:
He was able to make a full recovery and return to his prior activity level.

Author's Comments:
While the majority (at least 70%) of concussion symptoms improve by 2 weeks after injury, up to 15% of patients can have symptoms beyond 3 months. Risk factors for prolonged symptoms include prior concussion, female sex, and psychiatric diagnoses. Symptoms beyond 3 months, with no other cause, indicate post-concussive syndrome, but other pathologies should be considered, especially intracranial lesions.

Only a few cases of CSF leak after a sport-related concussion have been reported in the literature. None of these had a concomitant subdural hematoma. We hypothesize that volume loss from the CSF leak caused rupture of the bridging veins. CSF leak is essential to consider in persistent postural headaches after a concussion. Up to one percent of blunt head injuries have CSF leaks. While usually improving with rest, hydration, and caffeine, persistent leaks require treatment with blood patch or surgery.

Editor's Comments:
Cerebral Spinal Fluid (CSF) helps protect the brain from any movement related or impact injury. It also helps regular intracranial pressure. A CSF leak is also rare when there is not a fracture. Initial imaging was normal, however the patient's symptoms were still present weeks after the date of injury. Typically, a vast majority of concussions resolve around two weeks, and if symptoms still persist, a trial of amitriptyline is appropriate as treatment for post concussive syndrome. Unfortunately, this patient's headaches still persisted, despite the amitriptyline, and one should consider repeat imaging for further investigation.

References:
Eisinger RS, Sorrentino ZA, Cutler C, Azab M, Pierre K, Lucke-Wold B, Murad GJ. Clinical risk factors associated with cerebrospinal fluid leak in facial trauma: A retrospective analysis. Clin Neurol Neurosurg. 2022 Jun

Pettyjohn EW, Donlan RM, Breck J, Clugston JR. Intracranial Hypotension in the Setting of Post-Concussion Headache: A Case Series. Cureus. 2020 Sep 18;12(9).

Selassie AW, Wilson DA, Pickelsimer EE, Voronca DC, Williams NR, Edwards JC. Incidence of sport-related traumatic brain injury and risk factors of severity: a population-based epidemiologic study. Ann Epidemiol. 2013 Dec;23(12).

Thomas Decramer, Pieter Jan Van Dyck-Lippens, Tom P. Franken, Philippe Demaerel, Johannes van Loon, Tom Theys. A Small Leak Will Sink the Brain: Targeted C1-C2 Patching. World Neurosurgery. Volume 101, 2017, Pages 816.

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