SHM Converge Scientific Abstract ePoster Gallery-What a Headache! A Case of Spontaneous Intracranial Hypotension

Pdf Summary

A 61-year-old woman with asthma, hypothyroidism, and migraines presented with 6 weeks of severe headache, nausea, and a metallic taste. Her headache worsened when standing or with Valsalva and improved when lying flat, and standard migraine treatments failed. MRI brain with gadolinium showed classic signs of intracranial hypotension, including diffuse pachymeningeal enhancement, effacement of cisterns and sulci, pituitary enlargement, decreased mamillopontine distance, and mild cerebellar tonsillar ectopia.<br /><br />Because spontaneous intracranial hypotension (SIH) is usually caused by a spinal cerebrospinal fluid (CSF) leak, she underwent MRI of the entire spine. This showed several nerve root diverticula but no definite active leak. CT myelography was considered for better localization, but the patient chose empiric high-volume nontargeted epidural blood patching, which provided partial relief.<br /><br />The discussion emphasizes that SIH is an underrecognized and often misdiagnosed cause of orthostatic headache, frequently mistaken for migraine. It results from CSF loss, leading to traction on pain-sensitive dural structures and, in some cases, cranial nerve symptoms such as diplopia or dysgeusia. Spinal leaks may arise from nerve root diverticula, disc/osteophyte penetration of the thecal sac, or CSF-venous fistulas.<br /><br />Brain MRI is key for diagnosis, while whole-spine MRI can suggest but not precisely locate the leak. More definitive localization may require CT myelography or digital subtraction myelography. Treatment depends on leak identification: targeted epidural blood patch, surgical repair, or transvenous embolization. If the leak site remains unknown, empiric nontargeted blood patching is used.

Asset Subtitle

Bridget B. Hottenstein

Meta Tag

Author List Bridget B. Hottenstein, Reema Qureshi

Category Clinical Vignettes

Concept Spontaneous Intracranial Hypotension

Concept Orthostatic Headache

Concept Spinal CSF Leak

Concept Brain MRI

Concept Pachymeningeal Enhancement

Distinguished Non-Finalist

Presenter Organization Warren Alpert School of Medicine, Brown University Health

Presenting Author Bridget B. Hottenstein

Track Adult

Keywords

spontaneous intracranial hypotension

orthostatic headache

cerebrospinal fluid leak

pachymeningeal enhancement

epidural blood patch

MRI brain

spinal MRI

nerve root diverticula

CT myelography

dysgeusia

Spontaneous Intracranial Hypotension

Orthostatic Headache

Spinal CSF Leak

Brain MRI

Pachymeningeal Enhancement