70-year-old lady presented with one-month history of progressively worsening headaches, nausea and dizziness necessitating an emergency room visit. Patient underwent CT of the brain which revealed chronic subdural hematoma requiring admission for further management. Patient denied preceding trauma, anticoagulant or antiplatelet medication. She reported several intermittent throbbing episodes of headache associated with nausea/vomiting which were positional in nature, with remarkable improvement in symptoms on lying down. Patient had a history of hypertension, well controlled with lifestyle changes. Physical examination revealed an alert and oriented woman with normal neurologic and fundoscopic exam. Patient had reported an episode of a flu like illness a few weeks prior to onset of symptoms. Laboratory results were significant for mild normocytic anemia with normal platelets, INR and creatinine. Due to positional nature of headache, patient underwent MRI of the brain, which revealed pachy-meningeal enhancement and sagging midbrain indicative of intracranial hypotension. Imaging of spine revealed multiple peri-neural and Tarlov cysts within the thoracic and lumbar spine, however spinal leak couldn’t be demonstrated on CT myelogram. Patient initially was managed conservatively with caffeine and hydration. However due to persistent symptoms a ‘blood patch’ was performed with dramatic resolution of symptoms.
Spontaneous intracranial hypotension is a well described but a rarely diagnosed condition often associated with a delay in diagnosis ranging from days to years. It’s known to arise from a spontaneous CSF leak with unclear patho-physiology, but underlying structural weakness of the spinal meninges is suspected. One third of cases have preceding trivial trauma. Orthostatic episodic headache is the characteristic symptom but occasionally other headache patterns can occur. Associated symptoms including posterior neck pain/stiffness, diplopia, hypacusia, nausea and in severe cases cognitive disturbances occur. Magnetic resonance imaging has helped improve diagnostic yield with subdural fluid collections, pachy-meningeal enhancement, engorgement of venous structures, pituitary hyperemia and brain sagging being the classic findings. Myelography is used to identify sites of CSF leak although is not always seen. Treatment options include non-invasive measures like hydration, binders, caffeine which have limited efficacy. Autologous blood injection in the epidural space, known as ‘Blood patch’ remains the mainstay of treatment with spontaneous resolution of symptoms as seen in our patient.
Headache is a common complaint among patients in the inpatient setting. Spontaneous intracranial hypotension should be considered in the differential when spontaneous, subdural hematomas are identified on imaging. The early diagnosis and treatment lead to rapid resolution of symptoms and avoid readmissions.