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Spontaneous intracranial hypotension presenting as thunderclap headache: a case report.

Chang T, Rodrigo C, Samarakoon L - BMC Res Notes (2015)

Bottom Line: A 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture.Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak.Awareness of its varied spectrum of presentations would avoid inappropriate investigations, misinterpretation of imaging results and ineffective treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka. thashichang@gmail.com.

ABSTRACT

Background: Spontaneous intracranial hypotension is a rare but treatable cause of a disabling headache syndrome. It is characterized by positional orthostatic headache, pachymeningeal enhancement and low cerebrospinal fluid pressure. However, the spectrum of clinical and radiographic manifestations is varied and misdiagnosis is common even in the modern era of magnetic resonance imaging. Spontaneous intracranial hypotension presenting as thunderclap headache is recognized but rare.

Case presentation: A 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture. Gadolinium-enhanced cranial magnetic resonance imaging demonstrated generalized meningeal enhancement and normal magnetic resonance angiography while lumbar puncture revealed a cerebrospinal fluid opening pressure of less than 30 millimetres of water. Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak. The patient was managed conservatively with bed-rest, intravenous hydration, analgesics and an increased intake of oral coffee which led to a gradual relief of headaches in the upright posture.

Conclusions: Spontaneous intracranial hypotension can rarely present as thunderclap headache. Awareness of its varied spectrum of presentations would avoid inappropriate investigations, misinterpretation of imaging results and ineffective treatment.

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Gadolinium-enhanced cranial magnetic resonance imaging showing generalized, uniform pachymeningeal enhancement.
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Fig1: Gadolinium-enhanced cranial magnetic resonance imaging showing generalized, uniform pachymeningeal enhancement.

Mentions: Haematological and biochemical blood investigations including full blood count, electrolytes, random blood glucose, liver and renal function tests, erythrocyte sedimentation rate and C-reactive protein were normal. Electrocardiogram was normal. Computerised tomography (CT) scan of the head did not reveal any abnormality. However, gadolinium-enhanced magnetic resonance imaging (MRI) showed generalized meningeal enhancement (FigureĀ 1). The MR angiogram was normal.Figure 1


Spontaneous intracranial hypotension presenting as thunderclap headache: a case report.

Chang T, Rodrigo C, Samarakoon L - BMC Res Notes (2015)

Gadolinium-enhanced cranial magnetic resonance imaging showing generalized, uniform pachymeningeal enhancement.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4379701&req=5

Fig1: Gadolinium-enhanced cranial magnetic resonance imaging showing generalized, uniform pachymeningeal enhancement.
Mentions: Haematological and biochemical blood investigations including full blood count, electrolytes, random blood glucose, liver and renal function tests, erythrocyte sedimentation rate and C-reactive protein were normal. Electrocardiogram was normal. Computerised tomography (CT) scan of the head did not reveal any abnormality. However, gadolinium-enhanced magnetic resonance imaging (MRI) showed generalized meningeal enhancement (FigureĀ 1). The MR angiogram was normal.Figure 1

Bottom Line: A 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture.Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak.Awareness of its varied spectrum of presentations would avoid inappropriate investigations, misinterpretation of imaging results and ineffective treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka. thashichang@gmail.com.

ABSTRACT

Background: Spontaneous intracranial hypotension is a rare but treatable cause of a disabling headache syndrome. It is characterized by positional orthostatic headache, pachymeningeal enhancement and low cerebrospinal fluid pressure. However, the spectrum of clinical and radiographic manifestations is varied and misdiagnosis is common even in the modern era of magnetic resonance imaging. Spontaneous intracranial hypotension presenting as thunderclap headache is recognized but rare.

Case presentation: A 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture. Gadolinium-enhanced cranial magnetic resonance imaging demonstrated generalized meningeal enhancement and normal magnetic resonance angiography while lumbar puncture revealed a cerebrospinal fluid opening pressure of less than 30 millimetres of water. Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak. The patient was managed conservatively with bed-rest, intravenous hydration, analgesics and an increased intake of oral coffee which led to a gradual relief of headaches in the upright posture.

Conclusions: Spontaneous intracranial hypotension can rarely present as thunderclap headache. Awareness of its varied spectrum of presentations would avoid inappropriate investigations, misinterpretation of imaging results and ineffective treatment.

Show MeSH
Related in: MedlinePlus