Spontaneous intracranial hypotension with pseudo-subarachnoid hemorrhage

Excerpt

A 58-year-old man was presented with a sudden onset of a severe headache that lasted for 4 days, after which he came to us. Neurological examinations were normal. Neck stiffness was not observed. The initial computed tomography (CT) findings demonstrated effacement of the basal cistern and high-density along with a tentorium and sylvian cistern, which were initially diagnosed with subarachnoid hemorrhage (SAH) (Fig. 1a). Retrospectively, a small amount of subdural hematoma was also noted bilaterally (Fig. 1b). Aneurysmal SAH was suspected and emergent cerebral angiography performed, which demonstrated no abnormality. To identify the source of subarachnoid bleeding, a lumbar puncture was performed 6 days after the headache onset. Cerebrospinal fluid (CSF) with a xanthochromic appearance along with a composition of slight lymphocytic pleocytosis (6 cells/mm³) and increased protein (150 mg/ml) was obtained. The opening pressure was not measured. Cranial gadolinium enhanced magnetic resonance (MR) imaging demonstrated typical findings of spontaneous intracranial hypotension (SIH) (Fig. 2). The bilateral subdural hematomas were apparent and irrigated through burr holes, after which his symptoms completely resolved. At the 2-year follow up examination, the patient was free from symptoms and the there were no findings associated with SIH.

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