Chang Thashi, Rodrigo Chaturaka, Samarakoon Lasitha
Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka.
University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka.
BMC Res Notes. 2015 Mar 29;8:108. doi: 10.1186/s13104-015-1068-1.
Spontaneous intracranial hypotension is a rare but treatable cause of a disabling headache syndrome. It is characterized by positional orthostatic headache, pachymeningeal enhancement and low cerebrospinal fluid pressure. However, the spectrum of clinical and radiographic manifestations is varied and misdiagnosis is common even in the modern era of magnetic resonance imaging. Spontaneous intracranial hypotension presenting as thunderclap headache is recognized but rare.
A 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture. Gadolinium-enhanced cranial magnetic resonance imaging demonstrated generalized meningeal enhancement and normal magnetic resonance angiography while lumbar puncture revealed a cerebrospinal fluid opening pressure of less than 30 millimetres of water. Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak. The patient was managed conservatively with bed-rest, intravenous hydration, analgesics and an increased intake of oral coffee which led to a gradual relief of headaches in the upright posture.
Spontaneous intracranial hypotension can rarely present as thunderclap headache. Awareness of its varied spectrum of presentations would avoid inappropriate investigations, misinterpretation of imaging results and ineffective treatment.
自发性颅内低压是一种罕见但可治疗的导致致残性头痛综合征的病因。其特征为体位性直立性头痛、硬脑膜强化及脑脊液压力降低。然而，临床和影像学表现的范围各异，即便在磁共振成像的现代时代，误诊也很常见。以霹雳样头痛形式出现的自发性颅内低压已被认识到，但较为罕见。
一名41岁的斯里兰卡女性因霹雳样头痛伴恶心、呕吐就诊，但其头痛的特点是随体位变化，直立位时加重，仰卧位时缓解。钆增强头颅磁共振成像显示硬脑膜普遍强化，磁共振血管造影正常，而腰椎穿刺显示脑脊液初压低于水柱30毫米。磁共振脊髓造影未能确定脑脊液漏的部位。患者接受了保守治疗，包括卧床休息、静脉补液、止痛药物及增加口服咖啡摄入量，这使得直立位头痛逐渐缓解。
自发性颅内低压很少以霹雳样头痛的形式出现。认识到其多样的表现形式可避免不恰当的检查、对影像学结果的错误解读及无效治疗。
