Two cases of medically-refractory spontaneous orthostatic headaches with normal cerebrospinal fluid pressures responding to epidural blood patching: Intracranial hypotension versus hypovolemia and the need for clinical awareness
A 41-year-old male presented in Oct 2009 with subacute onset, severe bifrontal throbbing headaches for 1 month. It was precipitated within 10 min of standing and relieved after few minutes in the recumbent position. He was so incapacitated with his headache that he was very fearful of getting off his bed for activities of daily living. Rest of the history, clinical examination and routine laboratory parameters were unremarkable. On clinical suspicion of SIH, MRI brain was carried out, which revealed bilateral subdural hygromas [Figure –], diffuse meningeal enhancement [Figure ,], venous distension sign [], sagging of the brain and tonsillar herniation []. Contrast MRI spine did not reveal CSF leak. CSF opening pressure was 80 mm water. CSF analysis was normal. Patient did not respond to bed rest, analgesics and fluids. He responded remarkably to EBP with reduction of headache by 75% in 72 h, and was headache free after 4 weeks with no recurrence on follow-up. MRI after 3 months revealed resolution of findings [Figure –].