Probably incidentally, two periradicular arachnoid cysts were present on the left S2 and S4 roots ( Figure 4). There was a wide posterior S3–S4 dysraphism, and bilateral S3 bulky meningocele (32/22/22.5 mm on the right side and 27/16/21 mm on the left side) occupied the sacral canal ( Figures 2D, E) exerting significant mass effect with pressure atrophy of the S3, S4 bodies and of posterior vertebral elements. The medullary cone was in a low position (元), and the terminal filum was thickened and attached posteriorly at L4–L5. However, the examination revealed anterior and posterior epidural “banded” enhancement of the whole spine more evident at C2–C3 (with a maximum thickness of 6 mm) in the continuity of the infratentorial pachymeningeal thickening, probably reflecting engorgement of epidural venous plexuses. The cervicothoracic spinal cord morphology and signal were normal. We followed up with a contrast-enhanced MRI of the whole spine to search for a possible dural defect. Otherwise, the brain examination was normal. ![]() The MRI revealed diffuse, relatively uniform thickening and enhancement of pachymeninges, without pathological leptomeningeal enhancement ( Figures 1A, B), an enlarged pituitary gland with a cranially convex superior border ( Figure 1C) and slightly engorged dural venous sinuses and cortical veins, all findings suggestive of intracranial hypotension syndrome. ![]() A CT scan of the brain performed at admission was unremarkable.Ĭonsidering the sensitivity to changes in position, a characteristic element of SIH, a contrast-enhanced MRI of the brain was also performed ( Figures 1A– C). The physical exam was normal, without sensory or motor deficits, and without incontinence. The headache was holocephalic, exacerbated by the orthostatic position, slightly relieved by clinostatism, and it was not associated with neck stiffness, fever, nausea, or vomiting. No history of direct head trauma or whiplash was reported. Case presentation Patient 1Ī 37-year-old previously healthy female patient was admitted to our hospital for severe orthostatic headaches with onset 5 days prior, after a seemingly innocuous fall on the buttocks during a ballet lesson, which she was practicing as a hobby. We present two cases of intracranial hypotension with onset after a minor fall and, sustained carrying effort, respectively. CSF leakage is a known cause of spontaneous intracranial hypotension (SIH), an under-diagnosed although not so rare syndrome characterized by a classical triad of low cerebrospinal fluid pressure, orthostatic headache, and brain “sag” with diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI) ( 7, 8). Meningeal diverticula, also known as meningoceles, which may be found at single or at multiple levels simultaneously ( 4, 5), are frequently associated with connective tissue abnormalities, and develop spontaneously or after the healing of a dural tear ( 6). Dural tears may occur spontaneously or after deliberate or accidental disruption of the meninges ( 2, 3). Tears of the spinal dural membrane, rupture of a meningeal diverticulum, and development of CSF-venous fistulas are the major sources of cerebrospinal fluid leaks ( 1). In both patients, the clinical evolution was favorable under conservative treatment. ![]() An extensive extradural CSF collection, spanning the cervicothoracic region (C4–T10), was described in the second case. In the first case, a bone fragment pierced an incidental congenital meningocele creating a dural fistula. We describe two patients admitted to our hospital for severe headaches aggravated in the orthostatic position, with a recent history of minor trauma and sustained physical effort, respectively. Most meningeal lesions are found in the cervicothoracic region, followed by the thoracic region, and rarely in the lumbar region, and extremely rarely in the sacral region. Minor traumatic events rarely lead to CSF leakage, contrasting with iatrogenic interventions such as a lumbar puncture or spinal surgery, which are commonly complicated by dural tears. 3MedInst Romanian-German Diagnostic Center, Bucharest, RomaniaĬerebrospinal fluid (CSF) leakage is considered the cause of spontaneous intracranial hypotension (SIH), an important etiology for new daily persistent headaches and a potentially life-threatening condition.2Department of Neurology, National Institute of Neurology and Neurovascular Diseases, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania.1Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania.Dana Antonescu-Ghelmez 1,2 Ioana Butnariu 2 * Florian Antonescu 1,2 Cristina Maier 3 Adriana Moraru 2 Amanda Ioana Bucur 2 Daniela Nicoleta Anghel 2 Sorin Tuţă 1,2
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