Hemicranial postural headache as a first symptom of a spontaneous carotid cavernous fistula: A case report

RATIONALE

Spontaneous carotid cavernous fistula (CCF) is rare, and the expression of headache caused by it can be variable.

PATIENT CONCERNS

A case of a man hospitalized for high-intensity hemicranial headache which was aggravated by lying down and relieved when standing or sitting. The pain was of a pulsating character, localized on the right, behind the eye, followed by nausea and vomiting. He gradually appeared with ophthalmoplegia, decreased visual acuity and epistaxis.

DIAGNOSIS

Digital subtraction angiogram (DSA) showed a pseudoaneurysm arising from the internal carotid artery (ICA) that projected anteriorly and medially into the sphenoid sinus with occluded fistula.

INTERVENTIONS

The pseudoaneurysm was successfully treated with covered stent.

OUTCOMES

The patient was then followed up clinically at the outpatient and seen in the outpatient clinic with no further episodes of nasal bleeding or new neurologic deficit. The vision loss and ophthalmoparesis were unchanged.

LESSONS

Hemicranial postural headache may be the first and characteristic sign of spontaneous CCF.

Orthostatic Headaches Associated With Spontaneous Intracranial Hypotension and Autonomic Dysfunction-A Case Series in Young Patients

Background: Orthostatic headaches can be noted in spontaneous intracranial hypotension and orthostatic intolerance. We present a case series of young patients diagnosed with spontaneous intracranial hypotension and were treated for the same but subsequently developed orthostatic intolerance. Methods: We retrospectively reviewed charts for seven young patients with orthostatic headaches related to spontaneous intracranial hypotension and orthostatic intolerance. Results: Patients were diagnosed with spontaneous intracranial hypotension. Diagnosis was confirmed by identifying epidural contrast leakage and three of seven patients were noted to have early renal contrast excretion on computerized tomography myelography. Patients were treated with epidural blood patches. All patients showed persistent symptoms of autonomic dysfunction after treatment of spontaneous intracranial hypotension and orthostatic intolerance was confirmed with head-up tilt table test. Conclusions: Patients with spontaneous intracranial hypotension failing to improve following epidural blood patching should be evaluated for orthostatic intolerance.

Treatment of spontaneous intracranial hypotension: experiences in a UK regional neurosciences Centre

A robust treatment paradigm for spontaneous intracranial hypotension has yet to be agreed upon. We present retrospective data from the patient cohort at our UK regional neurosciences centre from 2010-2020 and describe our locally developed treatment pathway.Seventy-three patients were identified: 31 men and 42 women; mean age was 42 years. The majority presented with a headache of variable duration, and most had positive imaging. Very few patients (7%) responded to conservative treatment. Sixty-six underwent epidural blood patching, with 39 (59%) having a good response. Twenty-three patients underwent myelography and targeted treatment (injection of fibrin sealant at the leak site), with 13 (57%) showing a good response. One patient had successful surgery. The relapse rate after response to epidural blood patching was 10%, and after response to targeted treatment was 23%. Most patients who relapsed responded to repeated treatments.The outcome data for our diverse patient cohort shows the success of a staged approach to treatment. Relapse rates are low, and surgery is only rarely required. We use these data to inform our discussions with patients, and present them here to enable other centres to develop robust investigation and treatment paradigms of their own.

Epidural Contrast Volume on Post-Myelogram Lumbar CT Predicts the Rate of Subsequent Blood Patch Treatment

BACKGROUND AND PURPOSE

Headaches due to cerebrospinal fluid (CSF) leakage are a well-known complication of dural puncture. The purpose of this study was to determine whether the presence and volume of epidural contrast on postmyelogram CTs of the lumbar spine were associated with post-dural puncture headaches (PDPHs) requiring epidural blood patch (EBP) treatment.

METHODS

A retrospective case control study of all fluoroscopically guided lumbar myelograms performed over a 5-year period by a single radiology practitioner assistant was performed. Ten patients who underwent EBP treatment after their myelograms were identified. Forty-six patients with similar demographics who did not receive blood patches were then selected. CT-lumbar myelogram images of patients and controls were reviewed. The volume of epidural contrast was then quantified as "severe" or "mild." Severe epidural contrast was defined as contrast detected in the ventral epidural space, the extra-foraminal space, or extending greater than or equal to the length of two vertebral bodies from the level of dural puncture.

RESULTS

Some amount of epidural contrast was seen in all patients. However, a severe volume of epidural contrast was associated with increased risk for PDPH requiring an EBP (odds ratio = 37.00; 95% CI = 4.1-330.8, p = 0.0012).

CONCLUSION

Severe epidural contrast on postmyelogram CTs of the lumbar spine was associated with an increased risk of PDPH requiring EBP treatment. When present, this finding can alert the proceduralist that the patient may require closer observation and follow up with earlier intervention.

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.