Presentation
Persistent headache, vomiting, and visual disturbance after lumbar puncture.
Patient Data
Thin rim of bilateral subdural collections of CSF density fluid. No subdural hematomas. Otherwise normal CT brain.
Bilateral asymmetric subdural effusions with signal intensity higher than the CSF, right greater than left. No signs of subdural hemorrhage. Pachymeningeal thickening and homogeneous symmetric dural enhancement. Dural venous distention was noted involving the right transverse sinus (venous distention sign). A subtle decrease of fluid is seen within the optic nerve sheaths. No evidence of tonsillar ectopia.
The CSF spaces are of normal size. Gray-white matter differentiation is normal. Nonspecific white matter hyperintensity was seen in the right occipital periventricular white matter.
No midline shift. No infarction or bleeding. The major vascular voids appear unremarkable.
Features are in keeping with benign intracranial hypotension.
Case Discussion
Intracranial hypotension is defined when the opening pressure of cerebrospinal fluid is less than 6 cm H2O. It is caused by a CSF leak along the neuraxis which can be primary (spontaneous) or secondary to surgery, lumbar puncture, or trauma.
Middle-aged adults are more commonly affected with a female predilection.
Positional headache is the most common complaint.
Imaging has a critical role in diagnosing and identifying the leak.
A contrasted study must be used. Imaging findings include pachymeningeal thickening and enhancement, dural venous distension, tonsillar herniation, and subdural collections.
Identification of CSF leaks may be challenging. Most CSF leaks are seen in the cervical lumbar region which may result from rupture of nerve root diverticulum.
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