A case of spontaneous intracranial hypotension without any history of positional headache]

A 52-year-old woman was admitted to our hospital with sudden diplopia, right ophthalmalgia, and occipital pain. The nature of her headache was continuous, and changing her position provided no relief. Three weeks before her admission, she experienced continuous cough and rhinorrhea during a few days. On admission, her neurological examination revealed right abducens paralysis, and right lateral gaze aggravated diplopia. Brain magnetic resonance imaging scan demonstrated diffuse pachymeningeal enhancement by gadolinium. Radioisotope cisternography showed a leak of cerebrospinal fluid from near the third lumbar vertebra. The first lumbar puncture revealed an initial pressure of 0 mm H2O. She was given a diagnosis of spontaneous intracranial hypotension due to a leak of the cerebrospinal fluid. During her hospitalization, she complained of vertigo and nausea. We found horizontal gaze nystagmus to left side and sensorineural deafness in her left ear, which improved in a few days. After treatment by a lumbar epidural continuous infusion of saline and a lumbar epidural blood patch, her headache and abnormal MRI findings had improved. The continuous cough before her admission may be the cause of the leak of cerebrospinal fluid. We had difficulty in diagnosis only by the history and clinical examination, because she had no history of orthostatic headache.