Intracranial hypotension and PRES: case report

We report a case of a woman presenting, 7 days after epidural analgesia for a caesarean section, to the emergency room for a worsening of the headache and tonico-clonic seizures. MRI showed alterations suggestive of the presence of intracranial hypotension (IH) as well as evidence of posterior reversible encephalopathy syndrome (PRES). She was treated with a blood patch which leads to the prompt regression of the clinical symptoms and follow-up MRI, after 15 days, showed complete resolution of radiological alterations. The possible pathogenetic relationship between IH, secondary to the inadvertent dural puncture, and PRES is discussed. We suggest that venous stagnation and hydrostatic edema, secondary to intracranial hypotension, probably played a crucial role in the pathogenesis of PRES.

Epidural Blood Patches in a Patient With Multi-level Cerebrospinal Fluid Leakage That Was Induced by Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is considered to be a very rare disorder. It is characterized by an orthostatic headache that is aggravated with the patient in the upright position and it is relieved by the patient assuming the supine position. SIH is caused by a spontaneous spinal cerebrospinal fluid leakage without the patient having undergone trauma, surgery or dural puncture or having any other significant medical history. An autologous epidural blood patch (EBP) is effective in relieving SIH. We report here on a case of SIH with cerebrospinal fluid leakage at the upper cervical vertebral level and the middle thoracic vertebral level. The points of leakage were identified by radionuclide cisternography, and this patient was successfully managed by injecting an EBP at each level of leakage.

Headache in intracranial hypotension

We describe the headache characteristics of two patients with intracranial hypotension (IH) and correlate the magnetic resonance imaging (MRI) pattern to the clinical aspects of this type of headache. The first case was that of a patient with spontaneous IH, whereas the second patient had IH following rhinorrhoea. Cerebral computed tomography (CT) performed at presentation of symptoms was normal in both patients. Cerebral MRI in the first case showed meningeal contrast enhancement and an MRI pattern consistent with a subdural hygroma, while in the second case there was only a mild meningeal thickening. The symptoms improved spontaneously in both cases in about 2–3 months, confirming that invasive manoeuvres are not mandatory in these patients.