The domino effect of acephalgic spontaneous intracranial hypotension

Thunderclap headache revealing dural tears with symptomatic intracranial hypotension: Report of two cases

Cerebrospinal fluid (CSF) leakage is considered the cause of spontaneous intracranial hypotension (SIH), an important etiology for new daily persistent headaches and a potentially life-threatening condition. Minor traumatic events rarely lead to CSF leakage, contrasting with iatrogenic interventions such as a lumbar puncture or spinal surgery, which are commonly complicated by dural tears. Most meningeal lesions are found in the cervicothoracic region, followed by the thoracic region, and rarely in the lumbar region, and extremely rarely in the sacral region. We describe two patients admitted to our hospital for severe headaches aggravated in the orthostatic position, with a recent history of minor trauma and sustained physical effort, respectively. In the first case, a bone fragment pierced an incidental congenital meningocele creating a dural fistula. An extensive extradural CSF collection, spanning the cervicothoracic region (C4-T10), was described in the second case. In both patients, the clinical evolution was favorable under conservative treatment.

Pearls & Oy-sters: Postdural Puncture Headache, Cerebral Sinus Venous Thrombosis, and Reversible Cerebral Vasoconstriction Syndrome in the Peripartum Period

We report the case of a 34-year-old female patient complaining of headaches 1 day after childbirth, initially interpreted as postdural puncture headache (PDPH) and treated successfully with an epidural blood patch. Five days later, she presented with an acute proportional right sensorimotor hemisyndrome and a new-onset left-sided headache, attributed to a venous stroke from left-sided cerebral sinus venous thrombosis (CSVT). Simultaneously, we found radiologic signs of reversible cerebral vasoconstriction syndrome (RCVS), considered asymptomatic. We administered anticoagulant therapy to the patient, and she showed full motor recovery at 3-month clinical follow-up. PDPH, CSVT, and RCVS are well-known neurologic complications during the peripartum period. All 3 conditions present with headaches, and headache features may overlap, masking co-occurrence and making accurate diagnosis (differentiation) of these diseases difficult. Each disease can potentially lead to disabling deficits, but all respond to specific treatment. Knowledge of the causes of headaches in the peripartum period, their specific clinical characteristics, and potential complications helps to prioritize and interpret diagnostic tests to offer appropriate therapy.