Abstract 394: Resolution of Bilateral Subdural Hematomas Following Pseudomeningocele‐Induced Intracranial Hypotension Treated with Fibrin Sealant

Introduction CSF leaks lead to intracranial hypotension and is being increasingly diagnosed as a cause of headaches. These leaks may present simply as a headache but can also lead to severe neurological complications, such as brainstem herniation, bilateral subdural hematomas, and cranial nerve palsies. We present a case of a dural tear that resulted in a pseudomeningocele, which was treated successfully with fibrin sealant. Presentation A 67‐year‐old patient presented to the emergency department with a headache that had worsened acutely over the past 4 days, following several months of less severe symptoms. A CT scan of the head revealed isodense to hypodense components on the right and mixed attenuation components on the left, suggesting a subdural hematoma with mild mass effect. An MRI of the brain, both with and without contrast, showed subacute to chronic subdural hematomas with an acute component on the left side. The MRI also indicated diffuse smooth thickening and enhancement of the dura, drooping of the splenium, flattening of the ventral pons, and reduced ponto‐mamillary distance. A whole‐spine MRI, although motion‐degraded, did not reveal any CSF leak. The patient underwent an epidural blood patch placement to address the suspected CSF leak, but their headache did not improve. A repeat CT scan of the head showed mild worsening of the bilateral hematomas and midline shift. A dynamic myelogram revealed a ventral filling defect likely due to a T5‐T6 central and left paracentral disc extrusion, which was the origin of the dural tear and led to the development of a pseudomeningocele. The patient then received a CT‐guided transfemoral fibrin glue injection at T5/T6. Following this procedure, the patient experienced improvement in their headaches, and follow‐up images showed stable findings at 2 and 4 weeks. A repeat CT scan of the head at 10 weeks demonstrated significant improvement in the bilateral subdural hematomas. Discussion Treatment for CSF leaks ranges from simple observation to surgical repair in refractory and complicated cases. Typically, an epidural blood patch is the first‐line treatment and often resolves the headache. However, some cases remain refractory depending on the etiology of the CSF leak. Several endovascular treatments are under development, including embolization for CSF‐venous fistulas and fibrin sealant for other cases. Fibrin glue, a pharmaceutical product composed of human thrombin and fibrinogen, is introduced into the epidural space under image guidance. Fibrin sealant placement is a safe procedure and has emerged as a viable alternative for refractory cases.