Endocrine disturbances such as
diabetes insipidus (DI) and syndrome of inappropriate
antidiuretic hormone secretion (
SIADH) are recognized complications of
craniopharyngioma surgery, which occur due to damage to structures that produce or store
antidiuretic hormone (ADH).
Intracranial hypotension is a clinical syndrome that presents with
headache and typical radiological features and can occur due to a leak of cerebral spinal fluid (CSF) in operations that involve the opening of the arachnoid (e.g.,
craniopharyngioma surgery). We describe a patient presenting with
headache, radiological evidence of
intracranial hypotension, and chronic DI after
craniopharyngioma surgery. This occurred in the absence of evidence of a CSF leak. The
headache and radiological findings resolved after the identification and treatment of DI.
Intracranial hypotension may have occurred secondary to
dehydration in chronic DI. A 48-year-old woman presented with progressive visual field loss due to cystic recurrence of a
craniopharyngioma. She underwent redo (second) extended endoscopic transsphenoidal surgery, having previously undergone an uncomplicated debulking procedure two years prior. Her redo operation was uneventful, and her vision improved postoperatively. A lumbar drain was placed preoperatively to protect the skull base repair and was removed after 48 hours. In the initial postoperative period, she developed a clinical (
polyuria) and biochemical picture consistent with DI, subsequently reverting to a
SIADH, after which fluid and
sodium homeostasis appeared to normalize, and she was discharged. Two months after discharge, she re-presented with new
headaches eased by lying flat. Magnetic resonance imaging (MRI) brain showed bilateral convexity subdural effusions and diffuse pachymeningeal enhancement, suggesting
intracranial hypotension and raising concern for postoperative CSF leak. MRI spine did not show a CSF
fistula at the site of the previous lumbar drain. Transsphenoidal examination under
anesthesia showed a well-healed skull base repair and no evidence of CSF leak. She concurrently reported
polyuria and
polydipsia. A formal water deprivation test confirmed central DI. Treatment with
desmopressin improved her
headache, and a follow-up MRI brain showed resolution of the previous stigmata of
intracranial hypotension. This case report reminds physicians and neurosurgeons that systemic disorders (such as
dehydration) can cause
intracranial hypotension.