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Background Intrathecal injection is a rare complication of spinal anesthesia and an underreported complication of epidural blood patches. Although there are other reported cases of intrathecal blood injection, these cases lack confirmatory imaging and others report injection of mixed blood with other agents. Case presentation We present a case report of post-laminectomy cerebrospinal fluid leak who underwent epidural blood patch placement. CT and MRI brain imaging was obtained, depicting intrathecal blood products. The patient had subsequent seizures and respiratory distress, received supportive care, and returned to baseline after several days. Conclusion The patient’s clinical course illustrates the potential complications of blood products within CSF, including seizures and respiratory distress, which improved with supportive care in this case. Importantly, to our knowledge, this is the only report that clearly depicts injection of purely blood products, without other confounding agents (such as gadolinium), into intrathecal space and with diffuse spread through the CSF as visualized on CT and MRI imaging.

We present a case of a man with headache and progressive behavioural disturbance. His cognitive decline progressed over a few months such that he was unable to hold a conversation or carry out any daily tasks such as washing and dressing. He had some upper motor neurone signs in his limbs and features of brainstem dysfunction including dysarthria and ocular abnormalities. His brain magnetic resonance imaging showed signs of brain ‘sagging’. He was thought to have frontotemporal brain sagging syndrome. Prior to any treatment, he began to improve. Over the course of a week he became markedly better, was back to normal within 3 months and remains so 7 months later. We propose that resolution of spontaneous intracranial hypotension led to resolution of frontotemporal brain sagging syndrome. We believe this is the first case described where this has occurred without any intervention. It is important to recognise this condition as a potentially reversible cause of dementia.

This paper reports 14 patients with idiopathic intracranial hypertension (IIH) who experienced immediate and sustained resolution of their IIH; 13 in the setting of a low-pressure headache and 1 who underwent lumbar drainage for 4 days draining the cerebrospinal fluid (CSF) at a rate of 5–15 mL/h. These observations, if confirmed, suggest that draining CSF using a temporary lumbar drain draining CSF at a rate greater than it is produced may potentially have a pivotal role in the management of IIH.

Objective: This Evidence-Based Case Management article evaluates and grades the evidence for two anesthesiology-related interventions: prophylaxis after unintentional meningeal puncture and treatment of spontaneous intracranial hypotension (SIH). Methods: A search was made of relevant English language clinical studies or reports pertinent to the topic of low-pressure headache, but excluding the treatment of meningeal puncture headache. Results: Thirty-seven case reports, case series, and clinical trials were included to develop the best available evidence-based recommendations for the prophylaxis of unintentional meningeal puncture and for the treatment of SIH. Conclusion: The highest quality randomized controlled trials suggest that prophylactic epidural blood patch (EBP) does not reduce the incidence of headache after unintentional meningeal puncture. The weight of existing literature supports EBP as an initial treatment of SIH, although its effectiveness does not approach that seen when EBP is used to treat meningeal puncture headache.

Introduction Obstetricians are familiar with postural headaches in their postpartum patients following spinal or epidural anaesthesia. The rare occurrence in the antepartum patient without inciting event, may pose a diagnostic and treatment dilemma with resultant prolongation of disabling headaches in affected patients. Awareness of this condition, if accurately diagnosed, may allow for earlier relief from disabling headache, which may take weeks to months to otherwise resolve. Case presentation A case of low-pressure or postural headache (spontaneous intracranial hypotension) in a 39-year-old Caucasian patient in early pregnancy follows. She was initially misdiagnosed with migraine headache, but subsequently thought to have low-pressure headache. Conclusions Obstetricians/neurologists need to be aware of the potential treatment options for pregnant patients. Due to the desire to limit caffeine (a standard treatment for low-pressure headache) in pregnancy, high-dose glucocorticoids may provide rapid relief without significant risk to the immunocompetent patient or the pregnancy. Our case offers a non-interventional approach in the pregnant patient with resultant quick response to treatment without significant adverse fetal risk.

This report is aimed at highlighting an important issue which may arise during the management of Idiopathic Intracranial Hypertension (IIH). Once the diagnosis of IIH has been confirmed by a combination of intracranial imaging and an elevated opening pressure at lumbar puncture, routine management involves the use of oral acetazolamide therapy. There is, however, a risk of a headache of high intracranial pressure being converted to one resulting from low intracranial pressure. This needs to be considered when reviewing these patients immediately following any diagnostic or therapeutic lumbar puncture (LP) that is performed, specifically ascertaining whether change in posture modulates the headache. Continuing acetazolamide in the presence of a low pressure headache can cause significant morbidity and should be avoided. Furthermore chronic acetazolamide therapy can induce low pressure symptoms. We describe four cases of IIH who have suffered as a result of over-treatment with acetazolamide.

We describe an interesting case of a 40-year-old lady who developed a spontaneous low-pressure headache whilst playing the bag-pipes. Playing wind instruments requires the generation of significant intra-thoracic pressure, which may have contributed to this musician's condition.

The syndrome of spontaneous intracranial hypotension (SIH) is an uncommon cause of postural headache. We describe three patients with classical low pressure headache associated with low CSF pressure, one of whom presented with sudden deafness and another with a unilateral VIth nerve palsy. Initial magnetic resonance imaging (MRI) scans revealed bilateral diffuse subdural fluid collections in all three cases. Follow up MRI scans performed on two patients at 6 months demonstrated partial resolution of the subdural collections but persistent striking meningeal enhancement despite clinical recovery. These findings differ from previous reported cases wherein clinical resolution of postural symptoms was preceded or closely followed by resolution of the MRI changes.

Low pressure headache typically occurs as a complication of dural puncture. "Spontaneous" low pressure headache is a relatively rare but under-recognised cause of intractable headache. Clinical suspicion of this condition warrants imaging of the brain to confirm the diagnosis; spinal imaging may be needed to identify the site of the leak. Epidural blood patching may be necessary to seal the leak - CT fluoroscopy may be helpful in delivering the patch directly to the site of the leak. Surgical intervention may be required in intractable cases. We describe a patient with spontaneous intracranial hypotension and review the clinical and radiological features of this syndrome.

Orthostatic headaches following dural puncture are well known to anaesthetists as well as other physicians who perform lumbar punctures. However, due to the progression of medical knowledge and newer diagnostic capabilities, many other causes of low pressure headaches have been recognised. Even though low pressure headache is largely under-diagnosed at present, with increased awareness it may become a common finding in the future. This article includes symptoms, diagnostic problems, and treatment options available for patients with low CSF pressure headache including post dural puncture headaches. DOI: http://dx.doi.org/10.4038/slja.v23i1.7801