Headache and abnormal brain MRI, what’s the diagnosis? Answer

Answer:

Coronal enhanced brain MR imaging study, showing diffuse enhancement of the pachymeninges (green arrows) as well as small bilateral subdural hematomas (red arrows)

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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Intracranial Hypotension:

Intracranial hypotension is caused by lumbar puncture or spontaneous CSF leak.
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

Intracranial hypotension with meningeal enhancement and “sagging” hind brain

Severe cases may develop diplopia (from cranial nerve palsy) or even subdural hematoma:
Subdural hematomas (white arrows) and meningeal ehancement (black arrows) in a case of intracranial hypotension

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

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).

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