Leaking the Diagnosis: A Case of Convulsive Status Epilepticus Due to Intracranial Hypotension

We describe a case of convulsive status epilepticus caused by intracranial hypotension, a complication of spinal surgery. Intracranial hypotension (IH) is typically characterized by an orthostatic headache. There have been limited case reports describing surgery-associated IH presenting with seizures.

Case report and review of the literature.

A 71-year-old woman with chronic back pain developed convulsive status epilepticus, characterized by generalized clonic seizures, immediately following scoliosis surgery. She had no history of seizures or other seizure risk factors. Despite treatment with intravenous midazolam, phenytoin, and lacosamide, seizures recurred five times over three hours. Thus, propofol and midazolam infusions were initiated. An electroencephalogram revealed burst suppression and bilateral hemispheric epileptiform discharges. Magnetic resonance imaging of the brain was consistent with IH without cortical vein thrombosis. Fluid from the surgical drains was positive for Beta-2 transferrin, consistent with cerebral spinal fluid. Her IH was likely due to an intraoperative dural tear causing status epilepticus. Over two weeks, she remained on bed rest, sedation was weaned, and phenytoin and lacosamide were tapered and discontinued. She had no further seizures.

IH is an under-recognized cause of seizure following the spinal or cranial surgery, lumbar puncture, or spinal anesthesia. Proposed mechanisms include traction on cortical structures, increased cerebral blood flow, and cortical irritation secondary to subdural hygromas.