Introduction

Spontaneous intracranial hypotension (SIH) is a frequent cause of debilitating orthostatic headache, with other neurological symptoms such as neck pain, nausea, and cranial nerves deficit. It can occur at all ages in both sexes. Brain MRI was the most sensitive exam in detecting signs of SIH, showing subdural fluid collection, pachymeningeal enhancement or venous engorgement. Treatment protocols include conservative treatment (hydration and bed rest), an epidural blood patch (EBP) till surgical treatment. In these case series, we present two cases of SIH with unusual presentation and with no evidence of CSF leakage, successfully treated with an EBP.

Case report

Case 1. A 45-year-old man presented with history of neck pain and headache for 2 months that persisted in every position, associated with visual disturbance and loss of balance. The brain MRI showed subdural bifrontal fluid collection, diffuse pachymeningeal enhancement and venous engorgement. Conservative treatment was not efficacious, so a 20 ml-EBP was performed at lumbar level. The day after the patient reported a significant improvement of symptoms. The MRI demonstrated normalization of imaging findings.

Case 2. A 52 old man with acute myeloid leukemia and Wernicke syndrome presented with a history of progressive nystagmus, ataxia, and dizziness. The brain MRI showed bilateral frontal subdural fluid collections and pituitary hyperemia. A first EBP allowed significant reduction of symptoms and fluid collections. However, 1 month later, the patient complained again of confusion, nystagmus, and dizziness with evidence of bilateral fronto-parietal subdural collections. A second 20 ml-EBP was performed, with good symptoms control and reduction of pathological findings.

Conclusion

The diagnosis of SIH should be considered also in patients with atypical presentation. Large volume EBP can be a successful early treatment when conservative treatment fails, even if the exact leak location is unknown.