Clinical Features and Long-term Results of Spontaneous Intracranial Hypotension

Abstract

To the Editor: We read with great interest the article by Kong et al. (1), which consisted of a retrospective analysis of 13 patients with spontaneous intracranial hypotension (SIH). The follow-up magnetic resonance imaging (MRI) or radionuclide cisternography was performed for only six patients. Although in the last paragraph of discussion, the authors noted that the resolution of previous abnormal findings did not correspond with the clinical symptoms, we failed to see further imaging data on this subset of six patients. Comparative coronal MRI scans of a patient are shown in Figure 4, but then there is no cross-referencing with Table 1, which means that the reader will never know to which patient those images belonged. Therefore, despite the report on a considerable number of patients, the temporal course and the severity of gadolinium enhancement and a correlation of these changes with symptoms remained unanswered. We would like to present a case with emphasis on changes in MRI findings during the follow-up period. This 63-year-old history professor was admitted with persistent headache that began 3 months ago. The headache started from his neck and extended to his head. The headache persisted through the whole day and reappeared every morning. The headache was dull and rarely pulsating. He would be pain free when he lay down for rest and for only few minutes after he got up in the morning. He confessed that the pain would normally disappear 10 to 20 minutes after lying down. The intensity of the pain would increase with coughing or sneezing. Past medical and surgical history was positive for burr-hole drainage of a left frontoparietal subdural hematoma 5 years ago. Physical and neurological examinations were completely normal. MRI scanning with contrast agent showed linear diffuse pachymeningeal gadolinium enhancement (Fig. 1). There was no downward displacement of the cerebellar tonsils or midline structures. Lumbar puncture was performed and the opening pressure was found to be 3o mmH2O. Cerebrospinal fluid was colorless and no cell was found with cytology. Protein and glucose content were within normal limits. SIH was diagnosed and strict bed rest with oral hydration was undertaken. After 1 month, his headaches were completely gone. Radiodiagnostic studies, which were planned beforehand for demonstrating a possible cerebrospinal fluid leak, were deferred. There was no headache at all during a follow-up examination 3 months later. Follow-up MRI scans with gadolinium showed decreased pachymeningeal enhancement (Fig. 2). MRI scans with gadolinium should be performed for the follow-up of all patients with SIH regardless of whether the headaches were cured or remained. M. Murat Sumer Ismail H. Tekkok Ankara, Turkey