P 112 A case of spontaneous intracranial hypotension with bilateral subdural haemorrhages – the value of a second look

Abstract

Background Intracranial hypotension is a well-known side effect of lumbar puncture. Spontaneous intracranial hypotension (SIH) due to a persistent CSF leak is rare, fortunately. Epidural patch therapy is effective in most of the cases of SIH after exhaustion of pharmacotherapy. The accurate localisation of the CSF leak remains difficult in spite of the diagnostic means but is crucial to provide the most effective therapy. Aim To encourage repetitive diagnostic work-ups when the search for the CSF leak remained unsuccessful. Case presentation A 49-year-old woman presented in the emergency department with persistent headaches for two weeks having started occipitally, increasing with upright position. The headache had a piercing character, described as 8/10 on the visual analogue scale. The intake of NSAIDs relieved the pain only shortly. She didn’t complain about fever, vomiting or nausea. There was no history of headache in her family. In order to exclude a symptomatic headache, a lumbar puncture was performed with only a very small CSF yield. It showed only a moderate elevation of total CSF protein (80 mg/dl). A cMRI, performed an hour after the lumbar puncture, showed bilateral hygroma consistent with chronic intracranial hypotension. An MRI scan of the spine showed intraspinal extradural hygroma as well. A CT- myelography raised the suspicion of a leakage due to a thoracic osseous spur. A CSF scintigram and subsequent MRI scans did not reveal any CSF fistula. A subsequent trial with a lumbar as well as thoracic blood patch was done, the patient was discharged thereafter with an appointment for an MRI follow-up 14 days later. However, she had to show up in our emergency department the day after due to unbearable headaches and newly developed confusion. The repeated cMRI revealed progressive bilateral subdural haemorrhages and caudally shifted cerebellar tonsils. Another MRI of the cervical spine now displayed -surprisingly to us after such an extended diagnostic workup - a vast liquor leakage on the level of the 1st and 2nd cervical vertebrae. Result We found the reason for the patient’s complaints only after several diagnostic work-ups. Conclusion In some cases of SIH, just one work-up might not be enough to identify the correct site of the CSF leakage.