Rinsho Shinkeigaku (Clinical Neurology)

Case Report

A case of spontaneous intracranial hypotension with simultaneous CSF leaks at the upper and lower thoracic levels

Motomi Arai, M. D. , Ph. D. 1) , Tomosue Takada, M. D. 2) and Katsutoshi Ichijo, M. D. 3)

Departments of Neurology1), Anesthesiology2), and Radiology3), Seirei Mikatahara General Hospital

We presented a patient of spontaneous intracranial hypotension (SIH), in which radionuclide cisternography demonstrated multiple CSF leaks. A 51-year-old previously healthy woman awoke with a severe headache and nausea that were almost completely relieved by lying flat (day 1). The headache was not relieved by analgesics. On day 10, she visited our clinic. Neurological examination showed no abnormalities. A lumbar puncture revealed an opening pressure of 50 mm H2O, protein level of 64 mg/dl, 21 erythrocytes 21/μ l, and4lymphocytes/μ l. Cranial MRI on day 11 with gadolinium infusion demonstrated diffuse thickening and enhancement of the meninges. No signs of venous sinus thrombosis were identified. There was no downward displacement of the cerebellar tonsils. Indium-111 radionuclide cisternography demonstrated early accumulation of the tracer in the urinary bladder and CSF leakage at the upper thoracic level on the left side, at the lower thoracic level on both sides, and at the lumbar level. It is noteworthy that the scintigram taken 4 hours after tracer injection demonstrated CSF leakage at the injection site but not in the upper thoracic area. The patient kept sitting for about 20 minutes just before the images were obtained. Spinal MRI did not show meningeal diverticulum and epidural fluid collection. Ten days of bed-rest and transfusion failed to relieve the headache. Epidural patching with 7 ml of autologous blood performed at the Th 2/3 interspace partially relieved the headache. Five days later, a second epidural patching was performed at Th 11/12, which was slightly effective. A third epidural patching at L 3/4 was ineffective. On day 32, a fourth epidural patching was performed at Th1/2 while the patient was lying down on her left side. The postural headache disappeared. Repeated cranial MRI with gadolinium infusion performed on day 47 showed resolution of the abnormal findings. To our knowledge, this is the second case report of SIH with double CSF leaks.
To localize multiple leaks, radionuclide cisternography should be performed with a patient in various positions just before images are obtained.

(CLINICA NEUROL, 41: 775－779, 2001)
key words: spontaneous intracranial hypotension, cranial MRI, radionuclide cisternography, CSF leak, epidural blood patch

(Received: 1-Sep-01)