A rare clinical case report: Intracranial hypotension due to cerebrospinal fluid leak at the upper cervical spine
Main Article Content
Abstract
We report a rare case of intracranial hypotension (IH) of a 30-year-old female patient admitted with a two-week history of orthostatic headache and a history of vaginal delivery one month prior. Brain conventional MRI revealed diffuse dural thickening and enhancement, engorged venous sinuses, pituitary hypertrophy, and brain sagging, suggestive of IH. Heavily T2-Weighted Magnetic Resonance Myelography (HT2W-MRM) indicated a CSF leak at the high cervical region at the C1-2 level., Intracranial pressure measurement showed pressure < 5cmH2O. The patient was diagnosed with IH due to high cervical CSF leakage and was treated by an epidural blood patch. After two weeks, the patient showed improvement in both clinical symptoms and MRI findings.
Article Details
Keywords
Intracranial hypotension, heavily T2-weighted, cerebrospinal fluid leakage, dural patch
References
1. Chung SJ, Kim JS, Lee MC. Syndrome of cerebral spinal fluid hypovolemia: clinical and imaging features and outcome. Neurology. 2000; 55(9): 1321-1327. doi:10.1212/wnl.55.9.1321.
2. Swyden S, Carter C, Shah S u. Intracranial Hypotension. In: StatPearls. StatPearls Publishing; 2024. Accessed July 6, 2024. http://www.ncbi.nlm.nih.gov/books/NBK560764/.
3. Walker DG. Refractory headache due to spontaneous intracranial hypotension from a CSF leak at C1-2. J Clin Neurosci. 2003; 10(4): 482-485. doi:10.1016/s0967-5868(02)00304-1.
4. Schievink WI, Maya MM, Tourje J. False localizing sign of C1-2 cerebrospinal fluid leak in spontaneous intracranial hypotension. J Neurosurg. 2004; 100(4): 639-644. doi:10.3171/jns.2004.100.4.0639.
5. An S, Jeong HG, Seo D, et al. Heavily T2-Weighted Magnetic Resonance Myelography as a Safe Cerebrospinal Fluid Leakage Detection Modality for Nontraumatic Subdural Hematoma. J Korean Neurosurg Soc. 2022; 65(1): 13-21. doi:10.3340/jkns.2020.0326.
6. Dobrocky T, Winklehner A, Breiding PS, et al. Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences. American Journal of Neuroradiology. 2020; 41(7): 1309-1315. doi:10.3174/ajnr.A6592.
7. Kranz PG, Gray L, Amrhein TJ. Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions. Headache. 2018; 58(7): 948-959. doi:10.1111/head.13328.
8. Callen AL, Timpone VM, Schwertner A, et al. Algorithmic Multimodality Approach to Diagnosis and Treatment of Spinal CSF Leak and Venous Fistula in Patients With Spontaneous Intracranial Hypotension. American Journal of Roentgenology. 2022; 219(2): 292-301. doi:10.2214/AJR.22.27485.
9. Cerebrospinal fluid leak presented with the C1-C2 sign caused by spinal canal stenosis: a case report | BMC Neurology | Full Text. Accessed July 5, 2024. https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-020-01697-1.
10. Yousry I, Förderreuther S, Moriggl B, et al. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. AJNR Am J Neuroradiol. 2001; 22(7): 1239-1250.
11. Mokri B, Hunter SF, Atkinson JL, Piepgras DG. Orthostatic headaches caused by CSF leak but with normal CSF pressures. Neurology. 1998; 51(3): 786-790. doi:10.1212/wnl.51.3.786.
12. Wang DJ, Pandey SK, Lee DH, Sharma M. The Interpeduncular Angle: A Practical and Objective Marker for the Detection and Diagnosis of Intracranial Hypotension on Brain MRI. AJNR Am J Neuroradiol. 2019; 40(8): 1299-1303. doi:10.3174/ajnr.A6120.
13. Dobrocky T, Winklehner A, Breiding PS, et al. Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences. American Journal of Neuroradiology. 2020; 41(7): 1309-1315. doi:10.3174/ajnr.A6592.
14. Marcelis J, Silberstein SD. Spontaneous low cerebrospinal fluid pressure headache. Headache. 1990; 30(4): 192-196. doi:10.1111/j.1526-4610.1990.hed3004192.x.
15. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part I | Cochrane Library. Accessed July 6, 2024. https://www.cochranelibrary.com/central/doi/10.1002/central/CN-01368120/full.
16. Burnett CJ, White AJ, Vulcan MD. Epidural Blood Patch for Treatment of Postdural Puncture Headache in a Patient with Spinal Fusion and Recent Implantation of Intrathecal Pain Pump. OJAnes. 2013; 03(03): 168-169. doi:10.4236/ojanes.2013.33039.
17. Tubben RE, Jain S, Murphy PB. Epidural Blood Patch. In: StatPearls. StatPearls Publishing; 2024. Accessed October 14, 2024. http://www.ncbi.nlm.nih.gov/books/NBK482336/.
18. Rai A, Rosen C, Carpenter J, Miele V. Epidural Blood Patch at C2: Diagnosis and Treatment of Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol. 2005; 26(10): 2663-2666.
19. Kwon SY, Kim YS, Han SM. Spontaneous C1-2 cerebrospinal fluid leak treated with a targeted cervical epidural blood patch using a cervical epidural Racz catheter. Pain Physician. 2014; 17(3): E381-384.
2. Swyden S, Carter C, Shah S u. Intracranial Hypotension. In: StatPearls. StatPearls Publishing; 2024. Accessed July 6, 2024. http://www.ncbi.nlm.nih.gov/books/NBK560764/.
3. Walker DG. Refractory headache due to spontaneous intracranial hypotension from a CSF leak at C1-2. J Clin Neurosci. 2003; 10(4): 482-485. doi:10.1016/s0967-5868(02)00304-1.
4. Schievink WI, Maya MM, Tourje J. False localizing sign of C1-2 cerebrospinal fluid leak in spontaneous intracranial hypotension. J Neurosurg. 2004; 100(4): 639-644. doi:10.3171/jns.2004.100.4.0639.
5. An S, Jeong HG, Seo D, et al. Heavily T2-Weighted Magnetic Resonance Myelography as a Safe Cerebrospinal Fluid Leakage Detection Modality for Nontraumatic Subdural Hematoma. J Korean Neurosurg Soc. 2022; 65(1): 13-21. doi:10.3340/jkns.2020.0326.
6. Dobrocky T, Winklehner A, Breiding PS, et al. Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences. American Journal of Neuroradiology. 2020; 41(7): 1309-1315. doi:10.3174/ajnr.A6592.
7. Kranz PG, Gray L, Amrhein TJ. Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions. Headache. 2018; 58(7): 948-959. doi:10.1111/head.13328.
8. Callen AL, Timpone VM, Schwertner A, et al. Algorithmic Multimodality Approach to Diagnosis and Treatment of Spinal CSF Leak and Venous Fistula in Patients With Spontaneous Intracranial Hypotension. American Journal of Roentgenology. 2022; 219(2): 292-301. doi:10.2214/AJR.22.27485.
9. Cerebrospinal fluid leak presented with the C1-C2 sign caused by spinal canal stenosis: a case report | BMC Neurology | Full Text. Accessed July 5, 2024. https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-020-01697-1.
10. Yousry I, Förderreuther S, Moriggl B, et al. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. AJNR Am J Neuroradiol. 2001; 22(7): 1239-1250.
11. Mokri B, Hunter SF, Atkinson JL, Piepgras DG. Orthostatic headaches caused by CSF leak but with normal CSF pressures. Neurology. 1998; 51(3): 786-790. doi:10.1212/wnl.51.3.786.
12. Wang DJ, Pandey SK, Lee DH, Sharma M. The Interpeduncular Angle: A Practical and Objective Marker for the Detection and Diagnosis of Intracranial Hypotension on Brain MRI. AJNR Am J Neuroradiol. 2019; 40(8): 1299-1303. doi:10.3174/ajnr.A6120.
13. Dobrocky T, Winklehner A, Breiding PS, et al. Spine MRI in Spontaneous Intracranial Hypotension for CSF Leak Detection: Nonsuperiority of Intrathecal Gadolinium to Heavily T2-Weighted Fat-Saturated Sequences. American Journal of Neuroradiology. 2020; 41(7): 1309-1315. doi:10.3174/ajnr.A6592.
14. Marcelis J, Silberstein SD. Spontaneous low cerebrospinal fluid pressure headache. Headache. 1990; 30(4): 192-196. doi:10.1111/j.1526-4610.1990.hed3004192.x.
15. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part I | Cochrane Library. Accessed July 6, 2024. https://www.cochranelibrary.com/central/doi/10.1002/central/CN-01368120/full.
16. Burnett CJ, White AJ, Vulcan MD. Epidural Blood Patch for Treatment of Postdural Puncture Headache in a Patient with Spinal Fusion and Recent Implantation of Intrathecal Pain Pump. OJAnes. 2013; 03(03): 168-169. doi:10.4236/ojanes.2013.33039.
17. Tubben RE, Jain S, Murphy PB. Epidural Blood Patch. In: StatPearls. StatPearls Publishing; 2024. Accessed October 14, 2024. http://www.ncbi.nlm.nih.gov/books/NBK482336/.
18. Rai A, Rosen C, Carpenter J, Miele V. Epidural Blood Patch at C2: Diagnosis and Treatment of Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol. 2005; 26(10): 2663-2666.
19. Kwon SY, Kim YS, Han SM. Spontaneous C1-2 cerebrospinal fluid leak treated with a targeted cervical epidural blood patch using a cervical epidural Racz catheter. Pain Physician. 2014; 17(3): E381-384.