An Unusual Case of Post-Traumatic Headache Complicated by Intracranial Hypotension

Abstract

We present a case of post-traumatic headache complicated by intracranial hypotension resulting in an acquired Chiari malformation and myelopathy with syringomyelia. This constellation of findings suggest a possible series of events that started with a traumatic cerebral spinal fluid (CSF) leak, followed by descent of the cerebellar tonsils and disruption of CSF circulation that caused spinal cord swelling and syrinx. This unusual presentation of post-traumatic headache highlights the varying presentations and the potential sequelae of intracranial hypotension. In addition, the delayed onset of upper motor neuron symptoms along with initially normal head computerized tomography scan (CT) findings, beg the question of whether or not a post-traumatic headache warrants earlier magnetic resonance imaging (MRI).

Posttraumatic Headache

“…28 A cerebrospinal fluid (CSF) leak (e.g., from cribriform plate fracture or dural root sleeve tear) resulting in cerebrospinal hypovolemia is a rare cause of posttraumatic headache that should be considered in the appropriate setting. 29 These headaches typically have a prominent orthostatic component with worsening on standing and marked improvement/resolution with supination. If a CSF leak headache is present, imaging may show findings of pachymeningeal enhancement on MRI, subdural hygromas, engorgement of the pituitary gland, and brain sag with flattening of the pons on the clivus and/or sag of the cerebellar tonsils into the foramen magnum.…”

<p>Acute Visual Loss Secondary to Arnold Chiari Type I Malformation Completely Resolving After Decompressive Posterior Fossa Surgery</p>

“…Patients usually describe a dull occipital pain, accompanied by throbbing, nausea and vomiting, that is exacerbated by coughing, lack of sleep and alcohol consumption. 6 Both strabismus and diplopia were also absent. CM-I very often presents with strabismus, typically esotropia, pathophysiologically explained, for example, as a result of coexisting sixth nerve palsy.…”

Intracranial Hypotension in the Setting of Post-Concussion Headache: A Case Series

“…To our knowledge, no cases of post-concussive headache related to intracranial hypotension sustained during an athletic activity have been reported in the literature. One specific case of trauma-related post-concussive headache as a sequela of intracranial hypotension has been published [ 11 ]. This case showed similarities when compared to the two above: young, healthy male individual, improvement in symptoms when lying flat, initial head CT unremarkable, MRI findings (low lying cerebellar tonsils, sagging brainstem).…”