Acute intracranial posttraumatic CSF hypotension in a child: Case report on a difficult craniofacial trauma

We report the case of a 12-year-old child involved in an accident during a horse competition, with a severe head trauma, who developed acute intracranial hypotension due to a massive sphenoidal sinus and ethmoidal cerebrospinal fluid leakage. The patient presented with acute loss of vision and brain anoxic ischemic lesions associated with contusions, and internal carotid artery dissection. Anoxic ischemic lesions and carotid artery dissection can be explained by airways obstruction and direct mechanical trauma; however, loss of vision is not clearly related with a direct cause. Three mechanisms can be hypothesized to be responsible for the loss of vision. One involves acute intracranial hypotension caused by massive cerebrospinal fluid leakage determining a lowering of supratentorial structures and stretching the optic cranial nerves; the second relates to initial hypoxia due to airway obstruction; and the third involves a direct mechanical stress on the injured structures. Interestingly, the 3 pathogenetic mechanics are not mutually exclusive but their effects amplify each other. To the best of our knowledge, this is the first report describing a case of acute intracranial hypotension in a craniofacial injury.