Coronal enhanced brain MR imaging study, showing diffuse enhancement of the pachymeninges (green arrows) as well as small bilateral subdural hematomas (red arrows), all from intracranial hypotension.
The most likely diagnosis is intracranial hypotension, and while a lumbar puncture would rule out an infection, the spinal fluid cell count and protein will likely be (alarmingly) abnormal, and the procedure may further lower the pressure and make his symptoms worse.
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It presents with severe acute orthostatic HA. The headache is often felt mostly in the occipital or neck area, most likely from “sagging” of the cerebellar tonsils
at the base of the brain into the upper cervical cord.
Intracranial hypotension with meningeal enhancement and “sagging” hind brain
Subdural hematomas (white arrows) and meningeal ehancement (black arrows) in a case of intracranial hypotension
This syndrome will generally respond to a “blind” lumbar epidural blood patch
, either by sealing off the leak, or pushing the brain stem back up in to the skull:
Epidural blood patch for intracranial hypotension
Recalcitrant cases need to undergo a CT myelogram to identify the CSF leak, so that it can be addressed with surgery (dural patch).