- Department of Critical Care, Gopala Gowda Shanthaveri Memorial Hospitals, Mysore, Karnataka, India
- Department of Neurology and Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
Correspondence Address:
Raghunath Aladakatti
Department of Neurology and Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
DOI:10.4103/2152-7806.127756
Copyright: © 2014 Aladakatti R. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Aladakatti R, Sannakki LB, Cai PY, Derequito R. Thunderclap headache: It is always sub-arachnoid hemorrhage. Is it? – A case report and Review. Surg Neurol Int 21-Feb-2014;5:22
How to cite this URL: Aladakatti R, Sannakki LB, Cai PY, Derequito R. Thunderclap headache: It is always sub-arachnoid hemorrhage. Is it? – A case report and Review. Surg Neurol Int 21-Feb-2014;5:22. Available from: http://sni.wpengine.com/surgicalint_articles/thunderclap-headache-it-is-always-sub-arachnoid-hemorrhage-is-it-a-case-report-and-review/
Abstract
Background:Spontaneous intracranial hypotension (SIH) is one of the relatively misdiagnosed pathophysiological entities by virtue of its presentation. SIH is a condition involving reduced intracranial pressure usually secondary to dural tear. There is recent increase in reporting of its varied presentation in literature. Critical care physicians and neurosurgeons are recognizing it in higher numbers than before. SIH is characterized by sudden onset of orthostatic headache and may be associated with neck stiffness, nausea, vomiting, tinnitus, deafness, and cognitive abnormalities. Since its imaging characteristics resemble classic subdural hematoma from other causes wrong diagnosis and intervention might have devastating outcome.
Case Description:Here we discuss a case presented to us with severe headache of sudden onset without any associated problems. Patient was initially being treated as sinusitis and later diagnosed as bilateral subdural hematoma and surgical intervention was being considered. Thorough history taking and physical examination lead to strong suspicion of intracranial hypotension (IH) and patient showed dramatic improvement with epidural blood patch.
Conclusion:IH is a commonly misdiagnosed entity. A high index of suspicion is required for timely diagnosis, in order to minimize unwanted therapeutic interventions that can worsen the patient's condition and to help initiate early and simple interventions.
Keywords: Diagnosis, hypotension, intracranial, presentation, spontaneous
INTRODUCTION
The earliest reported case of symptoms as a result of intracranial hypotension (IH) was back in 1825 when vertigo and unsteadiness was described in a patient after removal of cerebrospinal fluid (CSF). Later in the 20th century, patients with headaches secondary to lumbar puncture (LP) were identified due to this entity.[
CASE HISTORY
0A 38-year-old Asian male presented with “sudden onset of worst headache of my life” that was generalized in nature and not associated with nausea, vomiting, or seizures. His past history was unremarkable. He was initially treated for sinusitis and prescribed a course of antibiotics and nasal decongestants, which initially improved his symptoms. After approximately one month, the patient's headache reoccurred and persisted. He was evaluated in the emergency room for recurrent head ache and urgent computed tomography (CT) brain revealed bilateral subdural collections (images not shown). With the diagnosis of bilateral subdural hematoma, he was considered for possible surgical intervention. Later careful history analysis revealed that his headache was worst when standing or sitting, but relieved when lying down. Other causes of headache were ruled out. On examination, all vital signs were within normal limits. There was no neck stiffness and no rash. Systemic examination was unremarkable. On neurological evaluation, patient was alert, oriented with intact higher cognitive function including speech. Cranial nerves including fundus exam, motor, sensory, and cerebellar examination demonstrated nonfocal neurological exam and no abnormality detected. Considering the patient's age, symptoms, unremarkable past medical problems, nonfocal exam, and radiological findings prompted us to consider SIH as the diagnosis and magnetic resonance imaging (MRI) brain was ordered to confirm it. MRI brain revealed [Figures
Figure 2
MRI Brain when patient presented with symptoms: T1 sagittal sequence of brain MRI show reduced mammillary body and pontine distance due to the descent of the mammillary body (arrow), crowding of posterior fossa due to brainstem descent, descent of cerebellar tonsils, sagging of tuber cinereum, inferior displacement of splenium and descent of the fastigium of the fourth ventricle
MRI myelography showed epidural fluid at the C2-C4 level with possible dural tear at C2 on right side and C3, C4 on the right side. Epidural fluid was also seen in the entire dorsal region and in the upper lumbar region without any obvious dural tear. The patient was scheduled for an epidural patch, which was performed at the cervical level using 12 cc of autologous blood. Symptoms resolved significantly after the epidural blood patch. Repeat CT head 3 months postblood patch showed resolution of the subdural fluid collection [
DISCUSSION
In 1942, the first case of IH was reported by Puech.[
Diagnosis
The International Classification of Headache Disorders has developed diagnostic criteria for SIH [
Treatment
The mainstay of SIH treatment is restoring the CSF pressure and relieving symptoms. There are multiple treatment theories that aim to achieve these goals, such as conservative medical therapy, epidural or intrathecal injections and surgery. Medical therapy, which includes bed rest, oral hydration, caffeine, and steroids, can be planned for patients with mild symptoms.[
CONCLUSION
SIH is a commonly misdiagnosed entity. A high index of suspicion is required for timely diagnosis, in order to minimize unwanted therapeutic interventions that can worsen the patient's condition and to help initiate early and simple interventions.
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