Hypotension of The Intracranial Circulation with CSF Leakage: A Rare Etiology of Misdiagnosed Orthostatic Headache; Using A Successful Blood Patching Technique: A Case Report and Literature Review

Abstract

Background: Spontaneous intracranial hypotension (SIH) is typically caused by spontaneous spinal leakage of the CSF, with unknown exact etiology, causing CSF volume depletion and craniospinal elasticity alterations. Often, SIH is misdiagnosed condition. Case Presentation: A 37-year-old female patient, presented with a four-month history of severe headaches. The first attack of headache, which was preseeded by one month of tinnitus, was in the fifth month of pregnancy. Physical examination and laboratory investigations were unremarkable. Brain MRI with and without contrast revealed thick diffuse meningeal enhancement. The MRA and MRV studies were unremarkable. Then, the patient’s headache worsens despite conservative therapy. MRI myelogram revealed a leak from the cervical nerve roots. Once the location of the leak was confirmed, a cervical epidural blood patch was performed successfully. The postoperative period, four days, was uneventful with clinical improvement of the patient’s headache and tinnitus. Discussion: Spontaneous intracranial hypotension is a challenging event that requires rapid diagnosis and management. Usually, the clinical history is suggestive of SIH diagnosis but still, it is underdiagnosed. Both imaging modalities and diagnostic criteria are important diagnostic tools for SIH. Several treatment modalities are available, including conservative options, epidural blood patches, and surgical intervention. Conclusion: Targeted epidural blood patch is a valid approach to managing the SIH that has been performed after a failed trial of conservative measures. We report a 37-year-old patient with a 4-month history of severe headaches and tinnitus found to be caused by SIH and managed by a cervical epidural blood patch.