Orthostatic headache as the presenting symptom of cervical spine metastasis

Orthostatic headache is a key symptom of intracranial hypotension; however, not all orthostatic headaches are caused by cerebrospinal fluid leaks leading to intracranial hypotension. We report here the unusual case of a 68-year-old man presenting with orthostatic headache in which compression of the C3 spinal nerve root by metastatic tumor invasion may contribute to the development of his orthostatic headache.     

Epidural Blood Patch for the Treatment of Abducens Nerve Palsy due to Spontaneous Intracranial Hypotension -A Case Report-

Intracranial hypotension is characterized by a postural headache which is relieved in a supine position and worsened in a sitting or standing position. Although less commonly reported than postural headache, sixth nerve palsy has also been observed in intracranial hypotension. The epidural blood patch (EBP) has been performed for postdural puncture headache, but little is known about the proper timing of EBP in the treatment of sixth nerve palsy due to intracranial hypotension. This article reports a case of sixth nerve palsy due to spontaneous intracranial hypotension which was treated by EBP 10 days after the onset of palsy.     

Spontaneous intracranial hypotension successfully treated by epidural patching with fibrin glue

We report a case of spontaneous intracranial hypotension due to a cerebrospinal fluid leak at the C2 level, which was successfully treated by epidural fibrin glue patching. Epidural blood patching was performed twice, first with 6 mL of autologous blood and then with 10 mL, but the intracranial hypotension was unresponsive. Although successful treatment of postdural puncture headache and persistent leak after intrathecal catheterization by epidural patching with fibrin glue has been reported, fibrin glue has not been previously applied in spontaneous intracranial hypotension. Our observation suggests that epidural patching with fibrin glue should be considered in patients with spontaneous intracranial hypotension, if epidural blood patching fails to resolve the symptoms.     

Headache in intracranial hypotension

Abstract We describe the headache characteristics of two patients with intracranial hypotension (IH) and correlate the magnetic resonance imaging (MRI) pattern to the clinical aspects of this type of headache. The first case was that of a patient with spontaneous IH, whereas the second patient had IH following rhinorrhoea. Cerebral computed tomography (CT) performed at presentation of symptoms was normal in both patients. Cerebral MRI in the first case showed meningeal contrast enhancement and an MRI pattern consistent with a subdural hygroma, while in the second case there was only a mild meningeal thickening. The symptoms improved spontaneously in both cases in about 2–3 months, confirming that invasive manoeuvres are not mandatory in these patients.     

Atypical Spontaneous Intracranial Hypotension With a Head‐Shaking Headache

Spontaneous intracranial hypotension (SIH) is typically characterized by orthostatic headache; however, various atypical manifestations of SIH have been reported recently. We report here the case of a 46‐year‐old man with headache secondary to SIH, which was nonorthostatic, triggered only when the patient shook his head. We suggest that SIH should be suspected in patients with headache induced by head‐shaking, even without orthostatic features, especially when the headache is accompanied by other symptoms commonly associated with SIH.     

A transient third cranial nerve palsy as presenting sign of spontaneous intracranial hypotension

Spontaneous intracranial hypotension is an uncommon cause of sudden and persistent headache: associated symptoms are common, among which there are cranial nerve palsies, especially of the abducens nerve. We report a case of a 21-year-old man with a transient and isolated third nerve palsy due to spontaneous intracranial hypotension. To our knowledge, there are only few reports in the literature of such association.     

Intracranial hypotension: aggravation of headache at high altitude

Spontaneous intracranial hypotension is an increasingly recognized disorder, often, although not always, characterized by the triad of low-opening cerebrospinal fluid pressure on lumbar puncture, postural headache, and diffuse parenchymal meningeal enhancement on magnetic resonance imaging of the head. We describe an unusual case of a patient with spontaneous intracranial hypotension presenting with postural headache and tinnitus, aggravated at high altitudes.     

Cerebral Venous Thrombosis in Spontaneous Intracranial Hypotension

Background and Objective.— The occurrence of cerebral venous thrombosis has been reported among patients with spontaneous intracranial hypotension, but a causal relationship has not been clearly established. We reviewed our experience with spontaneous intracranial hypotension and cerebral venous thrombosis and we reviewed the relevant literature to evaluate the relationship between these 2 entities. Methods.— We reviewed the medical records and imaging studies of a consecutive group of patients with spontaneous intracranial hypotension evaluated at a tertiary care center between 1/1/2001 and 12/31/2007. The main search strategy was a systemic review of journal articles in MEDLINE (1966 to January 2008). Results.— Among 141 patients with spontaneous intracranial hypotension, 3 (2.1%) were also diagnosed with cerebral venous thrombosis. Among these 3 patients and the 17 reported in the literature there were 11 men and 9 women with a mean age of 39.5 years. Radiographic or clinical evidence for spontaneous intracranial hypotension preceding cerebral venous thrombosis was found in most patients, while there was no evidence for cerebral venous thrombosis preceding spontaneous intracranial hypotension in any patient. Eight (40%) of the 20 patients were found to have a change in their headache pattern believed to be due to the development of cerebral venous thrombosis. Complications of cerebral venous thrombosis, eg, cerebral venous infarction, occurred in 8 patients (40%). Conclusions.— Spontaneous intracranial hypotension is a risk factor for cerebral venous thrombosis, but cerebral venous thrombosis is found in only about 2% of patients with spontaneous intracranial hypotension. A change in headache pattern is not a reliable predictor of the development of cerebral venous thrombosis in patients with spontaneous intracranial hypotension.     

Pathological contrast enhancement of the oculomotor and trigeminal nerves caused by intracranial hypotension syndrome

The typical symptom of intracranial hypotension syndrome is orthostatic headache. The headache may also be accompanied by neck pain and stiffness, low backache, radicular symptoms, quadriplegia, interscapular pain, nausea/vomiting, and cranial nerve involvement symptoms (hearing and visual problems, face pain and numbness, hypogeusia). Radiologically, on cranial magnetic resonance imaging, intracranial hypotension syndrome is characterized by dural thickening and contrast enhancement, subdural effusion, engorgement of the venous structures, sagging or downward displacement of the brain, and pituitary hyperemia. Although clinical findings related to cranial nerves 3 and 5 have been described in intracranial hypotension, pathological contrast enhancement of these nerves has not. We present a 32-year-old patient whose cranial magnetic resonance imaging shows bilateral pathological contrast enhancement of cranial nerves 3 and 5 and describe a new imaging finding in intracranial hypotension syndrome.     

Intracranial hypotension and PRES: case report

We report a case of a woman presenting, 7 days after epidural analgesia for a caesarean section, to the emergency room for a worsening of the headache and tonico-clonic seizures. MRI showed alterations suggestive of the presence of intracranial hypotension (IH) as well as evidence of posterior reversible encephalopathy syndrome (PRES). She was treated with a blood patch which leads to the prompt regression of the clinical symptoms and follow-up MRI, after 15 days, showed complete resolution of radiological alterations. The possible pathogenetic relationship between IH, secondary to the inadvertent dural puncture, and PRES is discussed. We suggest that venous stagnation and hydrostatic edema, secondary to intracranial hypotension, probably played a crucial role in the pathogenesis of PRES.     

Unusual cause of sudden onset headache: spontaneous intracranial hypotension

Spontaneous intracranial hypotension is a very distinctive but unusual cause of acute headache. The postural nature of the headache can be easily overlooked in the celerity to exclude subarachnoid haemorrhage. We describe the clinical and radiological features of a case that emphasizes some of the diagnostic difficulties. An approach to management and treatment for this condition is outlined.     

Spontaneous intracranial hypotension syndrome in a patient with marfan syndrome and autosomal dominant polycystic kidney disease

Intracranial hypotension is typically manifested by orthostatic headache. The most frequent underlying factor is cerebrospinal fluid leakage. It has been suggested that dural structural weakness in some connective tissue diseases may be responsible for dural tears and diverticula and consequently leakage. We present a case of spontaneous intracranial hypotension associated with Marfan syndrome and autosomal dominant polycystic kidney disease. The patient was treated successfully with epidural autologous blood patch. Dural involvements of these hereditary connective tissue diseases are also discussed.     

Thunderclap stroke: embolic cerebellar infarcts presenting as thunderclap headache

Thunderclap headache is known to be a presenting feature of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, and hypertensive reversible posterior leukoencephalopathy. We describe a case of thunderclap headache in the absence of focal, long-tract, or lateralizing neurological findings, as the primary clinical feature of embolic cerebellar infarcts. This case expands the differential diagnosis of thunderclap headache and reinforces the need for magnetic resonance imaging in the evaluation of such patients, even when neurologic examination, brain computed tomography, and cerebrospinal fluid analysis are normal.     

Headache Due to Spontaneous Intracranial Hypotension and Subsequent Cerebral Vein Thrombosis

Cerebral vein thrombosis (CVT) is a rare complication of spontaneous intracranial hypotension (SIH). When to suspect a thrombotic disorder during the course of intracranial hypotension is not fully elucidated. A 48‐year‐old woman was admitted because of SIH with no signs of CVT on neuroimaging. The occurrence of diplopia and blurred vision 12 days later led to the performance of further investigations, which revealed thrombosis of the left lateral sinus, in the absence of variations in the headache characteristics. Among the other 4 cases of SIH clearly preceding the occurrence of CVT reported so far, only one had a change in the headache pattern related to CVT development. Although a change in the characteristics of headache is considered a marker of CVT in patients with SIH, this is not invariably part of the clinical scenario. Any new neurologic finding on exam in the disease course should raise a suspicion of venous thrombosis, thus prompting further specific investigations.     

A case of spontaneous intracranial hypotension with typical magnetic resonance images

Spontaneous intracranial hypotension (SIH) is a rare syndrome defined by postural headache, associated with a low cerebrospinal fluid pressure, without history of previous dural trauma or invasive treatment on rachis. We reported a case of a patient with postural headache caused by SIH identified by magnetic resonance images and treated with saline solution infusion with complete remission of symptoms.     

Thunderclap headache caused by minimally invasive medical procedures: description of 2 cases

We report 2 very unusual cases of thunderclap headache complicating minimally invasive medical procedures. In the first case headache developed as the consequence of a pneumocephalus caused by an inadvertent intrathecal puncture during oxygen-ozone therapy for lumbar disk herniation. The second case involved intracranial hypotension, caused by the persistence of the needle, used for epidural anesthesia, and then penetrated in the subarachnoid space.     

Intracranial hypotension: the nonspecific nature of MRI findings

We present three patients who complained of postural headache related to different types of intracranial hypotension: spontaneous or primary, and secondary, but presenting the same findings on brain magnetic resonance imaging. Diffuse pachymeningeal gadolinium enhancement supports the belief that the enhancement is a nonspecific meningeal reaction to low pressure.     

Ruptured intracranial dermoid: an unusual cause of headache in an older patient

A 76-year-old woman with a history of migraine presented with worsening headache. Computerized tomography brain scan and magnetic resonance imaging brain scan showed the presence of fat globules in the cerebrospinal fluid space. This appearance was suggestive of ruptured intracranial dermoid. She recovered spontaneously. While headache is a known presentation of ruptured intracranial dermoid, the condition is unusual to present in older people.     

Orthostatic headache and bilateral abducens palsy secondary to spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is a well-documented syndrome characterized typically by a benign, self-limited course. Patients typically present with postural or exertional headaches that can be temporarily relieved by lying in a supine or recumbent position. A 35-year-old Caucasian male suffered orthostatic headache that developed to a bilateral abducens palsy. We ordered relative rest and the patient improved and completely recovered after 3 months. Although SIH is considered as a benign and self limited process it could also be associated with disabling complications. We should be aware of the possible complications and inform our patients. SIH can present with headache and bilateral abducens palsy even when the headache is improving.     

原发性低颅压综合征的临床表现与MRI诊断

目的：探讨原发性低颅压综合征的临床与MRI表现。方法：分析15例原发性低颅压综合征患者的临床资料、脑脊液生化及MRI表现。结果：15例患者均有体位性头痛,伴有或不伴有其他神经系统症状。脑脊液检查,脑脊液压力均低于70mmH20（1mmHzO=0．0098kPa）,生化检查9例正常。MRI检查硬脑膜均匀性增厚强化。经临床积极治疗,预后良好。结论：体位性头痛是低颅压综合征特征性临床表现,腰椎侧卧位穿刺脑脊液压力测量及头颅MRI检查具有诊断价值,临床积极治疗预后良好。