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A Case of Spontaneous Intracranial Hypotension with Associated Abducens Nerve Palsy and other Cranial Nerve Deficits
Namratha Prabhu MD1, Neha Pawar MD2, Shiva Sharma MD3, Joseph Poli MD1, Annie Philip MD1
1Department of Anesthesiology, University of Rochester Medical Center, Rochester, NY
2Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
3UTHealth Harris County Psychiatric Center, Houston, TX
Postural headache is commonly caused by cerebrospinal fluid (CSF) leak that can arise from procedural complications including errant epidural injection or lumbar puncture. Spontaneous CSF leaks can also occur due to non-iatrogenic causes (e.g. exercise) often times resulting in spontaneous intracranial hypotension (SIH). SIH is characterized by orthostatic (postural) headache, cranial nerve deficits (most commonly diplopia caused by abducens nerve palsy), nausea, nuchal rigidity, tinnitus, and photophobia. Diagnosis can be confirmed with MRI which may reveal diffuse enhancement of pachymeninges, subdural fluid collections, or sagging of the brain. SIH treatment may be supportive and includes hydration, analgesics, caffeine, and bed rest. Failure of supportive therapy may lead to treatment via epidural blood patch. If treatment with two epidural blood patches fails, myelography is then performed to detect the site of CSF leak and to guide fibrin glue (sealant) treatment or surgery.
29 y/o Caucasian M with previous history significant for anxiety, depression, and migraine headaches presented with a two-day history of bifrontal postural headache and mild nausea that commenced after an episode of exercise (running on elliptical machine). He denied vomiting, fever, nuchal rigidity, or photosensitivity. CT Head revealed no abnormalities and he received treatment with analgesics, hydration, and caffeine resulting in mild symptomatic improvement. Six days after his initial visit, he returned with persisting positional headache, new onset horizontal diplopia, decreased unilateral facial sensation, and tinnitus. MRI head/complete spine findings revealed sagging brainstem, crowding of foramen magnum, thickening of pachymeninges, CSF volume loss, and extradural CSF present along the ventral spinal canal from C3-C4 to T2-T3.
An epidural blood patch was performed at L3-L4 with injection of 19.5cc of autologous blood resulting in complete resolution of postural headache and mild improvement in diplopia. Five days later, the patient returned due to recurrence of postural headache, clear drainage from his eyes, and worsening horizontal diplopia. A second epidural blood patch was performed at L4-L5 using 22cc of autologous blood (7 days post-treatment with initial blood patch) resulting in minimal improvement of symptoms. He continued to be treated with conservative measures and MR myelogram did not reveal the location of CSF leak. At time of discharge, the patient experienced complete resolution of postural headache and non-diplopia cranial deficits with mild improvement in diplopia. He was prescribed ophthalmic prisms one month after discharge and two months post discharge, there was resolution of diplopia with the aid of ophthalmic prisms and no further recurrence of postural headache. Four months post discharge, the patient no longer required the use of ophthalmic prisms as diplopia completely resolved.
This case presents an example of SIH with postural headache and cranial symptoms of diplopia, tinnitus, and decreased facial sensation, all of which completely resolved after treatment with two epidural blood patches, except for diplopia which resolved later with use of ophthalmic prisms. Providers should be familiar with the complex presentation, treatment options (multiple blood patches, ophthalmic prisms, etc.), and gradual recovery process of diplopia associated with SIH.
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2. Schievink, W. (2006). Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension. JAMA, 295(19), p.2286-2296.
3. Kim, Y., Yoon, D. and Yoon, K. (2012). Epidural Blood Patch for the Treatment of Abducens Nerve Palsy due to Spontaneous Intracranial Hypotension-A Case Report. The Korean Journal of Pain, 25(2), p.112.
4. Schievink et al. Neurology 2016 July 20.