Intracranial hypotension secondary to spontaneous spinal cerebrospinal fluid leaks

Hipotensão intracraniana secundária a fístula liquórica espinhal espontânea

A 37-year-old woman presented with acute orthostatic hypotension and diffuse headache. Brain magnetic resonance imaging (MRI) revealed T2 hyperintense bilateral subdural effusions, diffuse pachymeningeal enhancement, slit ventricles and venous engorgement compatible with spontaneous intracranial hypotension. Single photon emission computed tomography with computed tomography (CT) and CT-cisternography showed a cerebrospinal fluid (CSF) leak at the left C1-C2 transition. Spontaneous intracranial hypotension is a rare cause of daily headache, which remains largely underdiagnosed¹,², and current evidence indicates that this condition is the result of a spontaneous CSF leak¹,²,³,⁴. This case illustrates the importance of CT-cisternography in the detection of CFS leak¹,²,³, allowing appropriate diagnosis and treatment.

Figure 1
Coronal T1 post contrast MRI demonstrates pachymeningeal enhancement (arrows); (B) axial T2 weighted MRI demonstrates subdural effusions (arrows); (C) Sagittal T1-weighted post contrast demonstrates engorgement of the superior sagittal sinus (straight arrow) and sagging of the brain (flattening of the pons and obliteration of prepontine cistern, curved arrow).

Figure 2
Sagittal and axial sections of CT-cisternography (A) axial and (B) sagittal show a C1-C2 left cerebrospinal fluid leak, with left fluid paravertebral collection (arrows).

References

• ¹ Schievink WI. Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia. 2008;28(12):1347-56. https://doi.org/10.1111/j.1468-2982.2008.01776.x
  » https://doi.org/10.1111/j.1468-2982.2008.01776.x
• ² Purdy RA. Understanding and managing spontaneous intracranial hypotension. Can J Neurol Sci. 2013;40(2):139-40. https://doi.org/10.1017/S0317167100013640
  » https://doi.org/10.1017/S0317167100013640
• ³ Mokri B. Spontaneous intracranial hypotension. Continuum (Minneap Minn). 2015;21 4 Headache:1086-108.
• ⁴ Hoffmann J, Goadsby PJ. Update on intracranial hypertension and hypotension. Curr Opin Neurol. 2013;26(3):240-7. https://doi.org/10.1097/WCO.0b013e328360eccc
  » https://doi.org/10.1097/WCO.0b013e328360eccc

Publication Dates

• Publication in this collection
  Mar 2017

History

• Received
  20 Jan 2016
• Accepted
  03 Oct 2016