Reversal of Coma With Trendelenburg Position in Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is a clinical and radiologic syndrome caused by spinal leakage of cerebrospinal fluid due to a dural tear, leaking meningeal diverticulum, or cerebrospinal fluid-venous fistula. Whereas the hallmark clinical feature of SIH is orthostatic headache, in rare instances, life-threatening complications may include altered consciousness and even coma as a result of extreme downward displacement of the midbrain and brainstem. We describe the clinical features, neuroimaging findings, management strategies, and short-term outcomes of 2 unique cases of severe SIH and the role of Trendelenburg position to reverse coma. Both patients demonstrated remarkable recovery to normal mentation (Glasgow Coma Scale score of 15) within 1 hour of placement in Trendelenburg position and recurrence of coma if allowed to be upright. These cases serve to highlight the importance of this simple maneuver for acute management of severe SIH while awaiting definitive leak localization and treatment.