{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:17:18Z","timestamp":1788308238044,"version":"build-2803163510"},"reference-count":21,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"10","license":[{"start":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T00:00:00Z","timestamp":1788739200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,9,7]]},"abstract":"\n BACKGROUND<\/jats:title>\n Spontaneous intracranial hypotension secondary to a CSF leak is a rare phenomenon that is often misdiagnosed and mismanaged. The authors present the case of a patient who presented with rapidly progressive symptoms leading to cerebral herniation, which was rapidly reversed with transvenous embolization of a high-flow CSF-venous fistula.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n A 57-year-old male presented with complaints of postural headaches that progressively worsened over 2 months. Imaging demonstrated bilateral subdural hygromas with effacement of the basal cisterns concerning for brainstem sag and impending brainstem herniation. While hospitalized, his neurological examination rapidly deteriorated, and he became comatose and required intubation. Digital subtraction myelography (DSM) demonstrated a high-flow CSF-venous fistula at the right side of T3\u20134, which was embolized transvenously. Following embolization, the patient awoke without significant neurological deficits. Postprocedure imaging showed a decrease in subdural hygromas and improved effacement of the basal cisterns and preprocedure brain sag. Three weeks postprocedure, he noted significant improvement in symptoms.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n The authors present the case of a patient who became acutely comatose due to brain herniation caused by a high-flow CSF-venous fistula. The patient was diagnosed and treated using DSM and transvenous CSF-venous fistula embolization with significant improvement of clinical symptoms and radiographic findings posttreatment.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE26338<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case26338","type":"journal-article","created":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:01:08Z","timestamp":1788307268000},"source":"Crossref","is-referenced-by-count":0,"title":["Rapid reversal of coma due to brainstem herniation after endovascular treatment of a high-flow cerebrospinal fluid\u2013venous fistula: illustrative case"],"prefix":"10.3171","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9980-9413","authenticated-orcid":true,"given":"Ismail S.","family":"Mohiuddin","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Weill Cornell Medical College, Cornell University, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Insun","family":"Chong","sequence":"additional","affiliation":[{"name":"Department of Radiology, Houston Methodist Hospital, Houston, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kurt A.","family":"Yaeger","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Weill Cornell Medical College, Cornell University, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"2","key":"bib1","series-title":"Pract Neurol","first-page":"146","article-title":"Complicated spontaneous intracranial hypotension treated with intrathecal saline infusion","volume":"16","author":"Stephen","year":"2016","unstructured":"Stephen CDRojas RLioutas VAPapavassiliou ESimon DK.Complicated spontaneous intracranial hypotension treated with intrathecal saline infusion. Pract Neurol. 2016;16(2):146-149. doi:10.1136\/practneurol-2015-001231"},{"key":"bib2","series-title":"Interv Neuroradiol","first-page":"15910199241272582","article-title":"Cerebrospinal fluid venous fistula causing spontaneous intracranial hypotension resulting in venous sinus thrombosis and coma","author":"White","year":"2024","unstructured":"White TGTurpin JShao MCerebrospinal fluid venous fistula causing spontaneous intracranial hypotension resulting in venous sinus thrombosis and coma. Interv Neuroradiol. 2024:15910199241272582. doi:10.1177\/15910199241272582"},{"key":"bib3","series-title":"World Neurosurg","first-page":"91","article-title":"Surgical treatment efficacy of CSF-venous fistulas: systematic review","volume":"161","author":"Konovalov","year":"2022","unstructured":"Konovalov AGadzhiagaev VVinogradov ENikitin NEliava SKonovalov N.Surgical treatment efficacy of CSF-venous fistulas: systematic review. World Neurosurg. 2022;161:91-96. doi:10.1016\/j.wneu.2022.02.036"},{"issue":"5","key":"bib4","series-title":"Neurosurgery","first-page":"931","article-title":"Cerebrospinal fluid-venous fistulas: a systematic review and examination of individual patient data","volume":"88","author":"Shlobin","year":"2021","unstructured":"Shlobin NAShah VNChin CTDillon WPTan LA.Cerebrospinal fluid-venous fistulas: a systematic review and examination of individual patient data. Neurosurgery. 2021;88(5):931-941. doi:10.1093\/neuros\/nyaa558"},{"issue":"6","key":"bib5","series-title":"AJNR Am J Neuroradiol","first-page":"730","article-title":"Efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension: a systematic review and evidence map","volume":"44","author":"Amrhein","year":"2023","unstructured":"Amrhein TJWilliams JWGray LEfficacy of epidural blood patching or surgery in spontaneous intracranial hypotension: a systematic review and evidence map. AJNR Am J Neuroradiol. 2023;44(6):730-739. doi:10.3174\/ajnr.A7880"},{"issue":"12","key":"bib6","series-title":"AJNR Am J Neuroradiol","first-page":"2685","article-title":"Outcomes of CT-guided targeted epidural patching for lateral dural tears in spontaneous intracranial hypotension: a multicenter retrospective cohort study","volume":"46","author":"Callen","year":"2025","unstructured":"Callen ALMontes DBhaumik DOutcomes of CT-guided targeted epidural patching for lateral dural tears in spontaneous intracranial hypotension: a multicenter retrospective cohort study. AJNR Am J Neuroradiol. 2025;46(12):2685-2692. doi:10.3174\/ajnr.A8886"},{"issue":"6","key":"bib7","series-title":"J Neurol Neurosurg Psychiatry","first-page":"752","article-title":"Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension","volume":"74","author":"de Noronha","year":"2003","unstructured":"de Noronha RJSharrack BHadjivassiliou MRomanowski CA.Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry. 2003;74(6):752-755. doi:10.1136\/jnnp.74.6.752"},{"issue":"9","key":"bib8","series-title":"Kaohsiung J Med Sci","first-page":"498","article-title":"Burr hole drainage for complicated spontaneous intracranial hypotension syndrome","volume":"24","author":"Liu","year":"2008","unstructured":"Liu YFLin HLCho DYChen CCLo YCChiou SM.Burr hole drainage for complicated spontaneous intracranial hypotension syndrome. Kaohsiung J Med Sci. 2008;24(9):498-502. doi:10.1016\/S1607-551X(09)70008-7"},{"key":"bib9","series-title":"Surg Neurol Int","first-page":"338","article-title":"When does too little pressure become too much? A case of spontaneous intracranial hypotension presenting with acute loss of consciousness","volume":"14","author":"Brosnan","year":"2023","unstructured":"Brosnan CDablouk MOHealy VMurray DSoleiman HABolger C.When does too little pressure become too much? A case of spontaneous intracranial hypotension presenting with acute loss of consciousness. Surg Neurol Int. 2023;14:338. doi:10.25259\/SNI_293_2023"},{"issue":"2","key":"bib10","series-title":"Neurol Med Chir (Tokyo)","first-page":"69","article-title":"Chronic subdural hematoma associated with spontaneous intracranial hypotension: therapeutic strategies and outcomes of 55 cases","volume":"56","author":"Takahashi","year":"2016","unstructured":"Takahashi KMima TAkiba Y.Chronic subdural hematoma associated with spontaneous intracranial hypotension: therapeutic strategies and outcomes of 55 cases. Neurol Med Chir (Tokyo). 2016;56(2):69-76. doi:10.2176\/nmc.oa.2015-0032"},{"issue":"3","key":"bib11","series-title":"Neurocrit Care","first-page":"390","article-title":"Coma from worsening spontaneous intracranial hypotension after subdural hematoma evacuation","volume":"12","author":"Dhillon","year":"2010","unstructured":"Dhillon AKRabinstein AAWijdicks EFM.Coma from worsening spontaneous intracranial hypotension after subdural hematoma evacuation. Neurocrit Care. 2010;12(3):390-394. doi:10.1007\/s12028-009-9323-8"},{"issue":"1","key":"bib12","series-title":"Neurology","first-page":"157","article-title":"Sinking brain syndrome: craniotomy can precipitate brainstem herniation in CSF hypovolemia","volume":"62","author":"Kelley","year":"2004","unstructured":"Kelley GRJohnson PL.Sinking brain syndrome: craniotomy can precipitate brainstem herniation in CSF hypovolemia. Neurology. 2004;62(1):157. doi:10.1212\/wnl.62.1.157"},{"issue":"12","key":"bib13","series-title":"Biomedicines","first-page":"3006","article-title":"Evolving management paradigms in dural arteriovenous fistulas: from classification to personalized endovascular therapy","volume":"13","author":"Shekar","year":"2025","unstructured":"Shekar VLucke-Wold B.Evolving management paradigms in dural arteriovenous fistulas: from classification to personalized endovascular therapy. Biomedicines. 2025;13(12):3006. doi:10.3390\/biomedicines13123006"},{"issue":"19","key":"bib14","series-title":"JAMA","first-page":"2286","article-title":"Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension","volume":"295","author":"Schievink","year":"2006","unstructured":"Schievink WI.Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295(19):2286-2296. doi:10.1001\/jama.295.19.2286"},{"issue":"11","key":"bib15","series-title":"AJNR Am J Neuroradiol","first-page":"1332","article-title":"Factors predictive of treatment success in CT-guided fibrin occlusion of CSF-venous fistulas: a multicenter retrospective cross-sectional study","volume":"44","author":"Callen","year":"2023","unstructured":"Callen ALCarlton Jones LCTimpone VMFactors predictive of treatment success in CT-guided fibrin occlusion of CSF-venous fistulas: a multicenter retrospective cross-sectional study. AJNR Am J Neuroradiol. 2023;44(11):1332-1338. doi:10.3174\/ajnr.A8005"},{"issue":"6","key":"bib16","series-title":"AJR Am J Roentgenol","first-page":"1418","article-title":"CSF\u2013venous fistulas: anatomy and diagnostic imaging","volume":"217","author":"Kranz","year":"2021","unstructured":"Kranz PGGray LMalinzak MDHouk JLKim DKAmrhein TJ.CSF\u2013venous fistulas: anatomy and diagnostic imaging. AJR Am J Roentgenol. 2021;217(6):1418-1429. doi:10.2214\/AJR.21.26182"},{"issue":"1","key":"bib17","series-title":"Neurosurgery","first-page":"E204","article-title":"Spontaneous intracranial hypotension resulting in coma: case report","volume":"59","author":"Sayer","year":"2006","unstructured":"Sayer FTBodelsson MLarsson EMRomner B.Spontaneous intracranial hypotension resulting in coma: case report. Neurosurgery. 2006;59(1):E204. doi:10.1227\/01.neu.0000243279.93846.67"},{"issue":"2","key":"bib18","series-title":"Asian J Neurosurg","first-page":"112","article-title":"Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension","volume":"8","author":"Chotai","year":"2013","unstructured":"Chotai SKim JHKim JHKwon TH.Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension. Asian J Neurosurg. 2013;8(2):112-115. doi:10.4103\/1793-5482.116390"},{"issue":"2","key":"bib19","series-title":"Neurocrit Care","first-page":"248","article-title":"Stroke and death due to spontaneous intracranial hypotension","volume":"18","author":"Schievink","year":"2013","unstructured":"Schievink WI.Stroke and death due to spontaneous intracranial hypotension. Neurocrit Care. 2013;18(2):248-251. doi:10.1007\/s12028-012-9800-3"},{"issue":"6","key":"bib20","series-title":"World Neurosurg","first-page":"1613","article-title":"Spontaneous intracranial hypotension: characteristics of the serious form in a series of 24 patients","volume":"84","author":"Idrissi","year":"2015","unstructured":"Idrissi ALLacour JCKlein OSchmitt EDucrocq XRichard S.Spontaneous intracranial hypotension: characteristics of the serious form in a series of 24 patients. World Neurosurg. 2015;84(6):1613-1620. doi:10.1016\/j.wneu.2015.07.002"},{"issue":"12","key":"bib21","series-title":"J Neurointerv Surg","first-page":"1256","article-title":"Clinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization","volume":"16","author":"Brinjikji","year":"2024","unstructured":"Brinjikji WMadhavan AGarza IClinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization. J Neurointerv Surg. 2024;16(12):1256-1263. doi:10.1136\/jnis-2023-021012"}],"container-title":["Journal of Neurosurgery: Case Lessons"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/12\/10\/article-CASE26338.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/12\/10\/article-CASE26338.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/12\/10\/article-CASE26338.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:01:08Z","timestamp":1788307268000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/12\/10\/article-CASE26338.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,7]]},"references-count":21,"journal-issue":{"issue":"10"},"URL":"https:\/\/doi.org\/10.3171\/case26338","relation":{},"ISSN":["2694-1902"],"issn-type":[{"value":"2694-1902","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,7]]}}}