Rapid Reduction of Syrinx Associated With Traumatic Intracranial Hypotension by Direct Surgery

A woman in her early twenties presented with cerebellar tonsillar herniation with syrinx in the cervicothoracic spinal cord manifesting as postural headache after suffering trauma to the hip. She was treated under a diagnosis of traumatic intracranial hypotension. Cranial magnetic resonance (MR) imaging demonstrated tonsillar herniation to the upper rim of the C1 lamina, associated with effacement of the basal cisterns and flattening of the pons against the clivus, sagging of the optic chiasm, and protrusion of the pituitary gland into the suprasellar cistern. Spinal MR imaging and computed tomography (CT) myelography showed cervicothoracic syrinx and arachnoid diverticulum. Three applications of epidural blood patches produced no improvement. Surgery identified cerebrospinal fluid leakage from two small holes in the spinal dural sac, slightly proximal from the origin of the left L1 root sleeve, and arachnoid diverticulum. These two holes were sutured and a few sheets of gelatin sponge were placed around the arachnoid diverticulum and sealed with fibrin glue. The cervicothoracic syrinx was reduced significantly and tonsillar herniation disappeared within 10 days. Simple surgical repair of the dural tears may rapidly improve symptoms and imaging findings in patients with tonsillar herniation caused by traumatic intracranial hypotension.