Spontaneous Intracranial Hypotension and Its Management with a Cervical Epidural Blood Patch: A Case Report
Challenging differential diagnosis, Rare disease
Raza Ali Akbar, Adeel Ahmad Khan, Glen Michael Fernandes, Ayman Zakaria Ahmed Mohamed, Ahmed Elsotouhy, Yasir Osman Mohamed Ali
Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
Am J Case Rep 2020; 21:e925986
Available online: 2020-08-12
Spontaneous intracranial hypotension (SIH) is a rare cause of postural headache. In most patients, the site of cerebrospinal fluid (CSF) leak is at the cervical or thoracic spinal level. The imaging modalities to establish the diagnosis of SIH include computed tomography (CT) and magnetic resonance imaging (MRI) of the brain, CT, and MRI myelography, and radionuclide cisternography. Treatment usually consists of conservative measures, but patients unresponsive to these treatments can be treated by epidural blood patch (EBP) administration at the site of CSF leak.
CASE REPORT: A 25-year-old-man presented with headache aggravated upon sitting or standing and relieved by lying supine or consuming coffee. There was no history of recent trauma, lumbar puncture, or spinal anesthesia. His neurological examination was unremarkable. MRI of his head and entire spine showed features of intracranial hypotension with no obvious CSF leak. He was treated conservatively but his symptoms persisted. CT spinal myelography showed significant leakage of contrast medium at the retrospinal region between C1 and C2 spinous processes. The patient underwent cervical EBP administration under fluoroscopic guidance. His symptoms resolved completely and he remains asymptomatic more than 6 months later.
CONCLUSIONS: SIH is an important cause of postural headache. In patients with non-resolving symptoms, further investigations are warranted to identify potential CSF leak. Patients found to have a CSF leak at the level of the cervical spine can be safely and effectively treated by cervical EBP administration.
Keywords: Blood Patch, Epidural, Cerebrospinal Fluid, Headache, Intracranial Hypotension, Myelography