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September 24, 2015: Intracranial hypotension

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September 24, 2015

Intracranial hypotension

Spontaneous intracranial hypotension is not an uncommon headache syndrome to recognize in neurology practice, but can prove to be challenging to diagnose and manage over time. Under homeostatic conditions, the brain is suspended in CSF, making its effective weight less. When there is loss of this CSF pressure, pain ensues, felt to be secondary to pain-sensitive structures such as the meninges and bridging blood vessels being pulled down. Although a post-LP headache is classic, other etiologies exist such as mild trauma, spontaneous leaks or connective tissue disorders. Most leaks occur at the cervicothoracic level or upper thoracic region. Myelogram imaging can be beneficial in locating a specific leak, as a target for a potential blood patch. MRI imaging often demonstrates diffuse, smooth meningeal enhancement, “sagging” of brain structures, pituitary enlargement, and decreased cistern size. Conservative treatment is adequate hydration and caffeine, although surgical repair is occasionally required.

Submitted by James Addington, M.D., Resident Physician, Department of Neurology, University of Virginia.

Disclosures: Dr. Addington is a member of the Resident and Fellow Section of Neurology.

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