Abstract
Spontaneous intracranial hypotension (SIH) is an important cause of new daily persistent headache. It is thought to be due to spontaneous spinal cerebrospinal fluid (CSF) leaks, which probably have a multifactorial etiology. The classic manifestation of SIH is an orthostatic headache, but other neurological symptoms may be present. An epidural blood patch is thought to be the most effective treatment, but a blind infusion may be ineffective. We describe the case of a young man who developed an acute severe headache, with pain worsening when assuming an upright posture and relief gained with recumbency. No history of previous headache, recent cranial or cervical trauma, or invasive procedures was reported. Magnetic resonance imaging showed pachymeningeal enhancement and other features consistent with SIH and pointed towards a cervical CSF leak site. After failure of conservative treatment, a targeted computer tomography-guided EBP was performed, with complete recovery.
Highlights
Spontaneous intracranial hypotension (SIH) is a known cause of new daily persistent headache
Since the cerebrospinal fluid (CSF) leak was located at a cervical level and the literature suggests that these cases are less likely to resolve with a blind epidural blood patch (EBP), we chose to perform a targeted computerized tomography (CT)-guided EBP
SIH is increasingly being recognized as a cause of new daily persistent headache with an estimated annual incidence of 5/100,000 and an incidence peak of around 40 years of age [1, 2]
Summary
Spontaneous intracranial hypotension (SIH) is a known cause of new daily persistent headache. The classic feature is an orthostatic headache, other symptoms related to the pathophysiology of SIH, such as neck pain or stiffness, nausea, vomiting, imbalance, or visual complaints, may be present with variable clinical severity. Conservative treatment is usually attempted first; this approach is unsuccessful in many patients. In these cases, an epidural blood patch (EBP) is usually considered. It is common to perform a blind EBP, but it can be ineffective and several trials may be necessary to achieve success, with some patients being refractory to this approach. A targeted CT-guided EBP is a more recent treatment option, with a higher success rate reported, but technical expertise is needed
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