title: Teaching neuroimages: a dangerous complication of spontaneous intracranial hypotension.
abstract: A 43-year-old man presented with a nontraumatic orthostatic headache, spatial disorientation, and visual hallucinations ("colored flames"). General and neurologic examination were normal. Turbo spin echo T2-weighted MRI showed bilateral subdural fluid collection and venous sinus engorgement (figure, A), suggesting spontaneous intracranial hypotension (SIH). Two subdural hematomas were also found, the biggest (2.5 cm) with mass effect in the left hemisphere (figure, B). Spine MRI identified a small radicular cyst emerging from the left T1-T2 foramen as the putative cause of CSF leakage (figure, C and D). The patient underwent drainage of the largest hematoma with benefit. Though initially planned, epidural blood patch and surgical treatment of the radicular cyst were not performed because clinical and radiologic findings improved with hematoma drainage, bed rest, and hydration. At a 3-month follow-up, MRI documented complete resolution of the subdural collection and dimensional stability of the radicular cyst. SIH is often considered benign and treated conservatively,(1)but it can rarely manifest with serious complications requiring rapid surgical evaluation.(2).
authors.affiliation: From the Center of Excellence on Headache (C.T., E.T., A.D.V., M.A.G.), Department of Medicine and Science of Aging (C.T., E.T., M.T., A.M., M.A.G.), and Institute for Advanced Biomedical Technologies (M.C.), "G. d'Annunzio" University, Chieti, Italy; and Neurology Ward (M.V.D.A.), S. S. Annunziata Hospital, Chieti, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Tana
authors.forename: Massimo
authors.initials: M
authors.lastname: Caulo
authors.forename: Emmanuele
authors.initials: E
authors.lastname: Tafuri
authors.forename: Angelo
authors.initials: A
authors.lastname: Di Vincenzo
authors.forename: Marco
authors.initials: M
authors.lastname: Tana
authors.forename: Maria Vittoria
authors.initials: MV
authors.lastname: De Angelis
authors.forename: Andrea
authors.initials: A
authors.lastname: Mezzetti
authors.forename: Maria Adele
authors.initials: MA
authors.lastname: Giamberardino
mesh_terms: D000328:Adult; D001921:Brain / Q000473:pathology*; D006801:Humans; D019585:Intracranial Hypotension / Q000150:complications*; D008279:Magnetic Resonance Imaging; D008297:Male