Fisher
et al. [
2] reported that vasospasm was found in almost all cases with a thick and widespread subarachnoid clot on a CT scan (group 3 according to their grading scale). That is because some spasmogenic substances produced from a clot around the cerebral arteries cause cerebral vasospasm. Cisternal irrigation therapy with urokinase (UK) has been performed to prevent symptomatic vasospasm by dissolving and removing SAH [
2,
3]. Kodama
et al. reported that complications occurred in eight patients during irrigation therapy; two patients experienced seizures, two patients developed meningitis, and four patients had an intracranial hemorrhage. However, all of these patients recovered without neurological deficits [
3].
In this case, the SAH was very thick and a severe vasospasm was easily predicted to occur. We followed the protocol used in the previous report [
3] and the SAH was washed out dramatically without the complications described. However, brain sagging occurred soon after the irrigation. We followed the same protocol as previous irrigations but have never experienced this complication. Intracranial hypotension is also associated with brain sag [
4]. A retrospective study found that 48% of patients with intracranial hypotension also had descent of the brain [
5]. Patients can have slit ventricles, distortion of the brain stem, and cerebellar tonsillar herniation [
6]. Brain sagging can result in transtentorial descent of the diencephalon, potentially leading to changes in consciousness [
7]. In this case, the distance was the widest soon after the irrigation (Figure
1e) and was gradually reducing (Figure
1f, g). As his intracranial hypotension improved, his CSF pressure elevated and he started to suffer from hydrocephalus. Surprisingly, the pressure increased to 40cmH
2O. We hypothesize that the malabsorption of cerebrospinal fluid (CSF) usually seen after SAH became apparent as the intracranial hypotension was resolved.
Treatment options include conservative medical therapy, epidural or intrathecal injections, and/or surgery. Medical therapy involves bed rest, oral hydration, caffeine, and/or steroids [
8]. Hydration aims to increase CSF volume. The most commonly reported treatment for intracranial hypotension is an epidural blood patch (injecting autologous blood into the spinal epidural space) [
9]. In this case, we inserted the spinal drainage tube on the first attempt, and there was no leakage around the tube. After the tube was removed, his lumber spinal MRI scan showed no CSF leakage. Therefore, we did not attempt a blood patch, and focused on hydration and head-down positioning. The brain sagging recovered without the use of a blood patch.