Answer for BIR CoW 14 Sep 2025
INTRACRANIAL HYPOTENSION
Findings
L5, S1 post laminectomy changes noted with adjacent T2 hyperintense / T1 hypointense collection measuring 1.7 x 2.3 x 3.2 cm (anteroposterior x transverse x cranio caudal) noted in L5-S1 level near the post op site and surrounding T2 / STIR hyperintense region noted reflecting edema. Evidence of posterior epidural collection of cerebrospinal fluid intensity noted in dorsal spine extending from D2 to D9 vertebral body level causing ventral displacement of dura and cord. On contrast administration, heterogenous enhancement noted involving the post operative site of lower lumbar region. There is multifocal smooth dural enhancement noted throughout the spine. Known case of L5-S1 IVDP, S/p decompression and laminectomy. Present study shows, Post op changes with adjacent T2 Hyperintense collection as mentioned Posterior epidural collection of cerebrospinal fluid intensity in dorsal spine causing ventral displacement of dura and cord. Multifocal smooth dural enhancement throughout the spine Bilateral frontoparietotemporal T2 / FLAIR hyperintense subdural collection with diffuse pachymeningeal enhancement. Features of intracranial hypotension.
Discussion
Intracranial hypotension (IH) is an uncommon, benign, and usually self-limiting condition caused by low cerebrospinal fluid (CSF) pressure, usually due to CSF leakage. The dominant clinical finding is an orthostatic headache. Other common clinical features include fever, nausea, vomiting, and tinnitus. Magnetic resonance imaging (MRI) plays an important role in the diagnosis and follow-up of patients with IH. Intracranial hypotension is of either primary (spontaneous intracranial hypotension – SIH) or secondary origin, e.g. iatrogenic or traumatic. Spontaneous intracranial hypotension is believed to occur as a result of trivial trauma and weakness in the dural sac due to spontaneous dural dehiscence and dural tears caused by degenerative causes. There is also an association with connective tissue disorders such as Marfan and Ehlers-Danlos syndromes. Secondary intracranial hypotension may be caused by injury of the dura mater, e.g. following cranial or spinal surgery, lumbar puncture, spinal anaesthesia, placement of ventriculo-peritoneal shunts, and craniospinal trauma Typically, IH is caused by leakage of CSF through the spinal dural sac. CSF leakage is broadly divided into three commonly observed patterns: fast leaks, slow leaks, and cases in which no leak is visible despite the presence of other clinical and imaging signs of IH The main MRI finding is a characteristic diffuse pachymeningeal enhancement. Other findings include sagging of the brain, pituitary enlargement, subdural fluid collections (usually hygromas, less commonly haematomas), posterior lobe pituitary haematomas, diffuse dural enhancement of the spinal canal, spinal epidural fluid collection, distension of the spinal epidural venous plexus, and abnormal intensity around the root sleeves Treatment: Headaches usually resolve after bed rest and conservative treatment. Lying position decreases pressure in the region of CSF leakage and allows recovery at the site of leakage. Blocking the adenosine receptors with oral or intravenous caffeine and theophylline induces arterial contraction and consequently reduces intracranial blood flow and venous engorgement, which relives symptoms Intravenous or oral hydration and steroid therapy also lead to positive outcomes If this is not enough, autologous epidural blood patch may be administered intrathecally, which leads to sealing of the site of leakage with a formed clot. Surgical correction of dural tears or other meningeal defects may be performed
Findings
L5, S1 post laminectomy changes noted with adjacent T2 hyperintense / T1 hypointense collection measuring 1.7 x 2.3 x 3.2 cm (anteroposterior x transverse x cranio caudal) noted in L5-S1 level near the post op site and surrounding T2 / STIR hyperintense region noted reflecting edema. Evidence of posterior epidural collection of cerebrospinal fluid intensity noted in dorsal spine extending from D2 to D9 vertebral body level causing ventral displacement of dura and cord. On contrast administration, heterogenous enhancement noted involving the post operative site of lower lumbar region. There is multifocal smooth dural enhancement noted throughout the spine. Known case of L5-S1 IVDP, S/p decompression and laminectomy. Present study shows, Post op changes with adjacent T2 Hyperintense collection as mentioned Posterior epidural collection of cerebrospinal fluid intensity in dorsal spine causing ventral displacement of dura and cord. Multifocal smooth dural enhancement throughout the spine Bilateral frontoparietotemporal T2 / FLAIR hyperintense subdural collection with diffuse pachymeningeal enhancement. Features of intracranial hypotension.
Discussion
Intracranial hypotension (IH) is an uncommon, benign, and usually self-limiting condition caused by low cerebrospinal fluid (CSF) pressure, usually due to CSF leakage. The dominant clinical finding is an orthostatic headache. Other common clinical features include fever, nausea, vomiting, and tinnitus. Magnetic resonance imaging (MRI) plays an important role in the diagnosis and follow-up of patients with IH. Intracranial hypotension is of either primary (spontaneous intracranial hypotension – SIH) or secondary origin, e.g. iatrogenic or traumatic. Spontaneous intracranial hypotension is believed to occur as a result of trivial trauma and weakness in the dural sac due to spontaneous dural dehiscence and dural tears caused by degenerative causes. There is also an association with connective tissue disorders such as Marfan and Ehlers-Danlos syndromes. Secondary intracranial hypotension may be caused by injury of the dura mater, e.g. following cranial or spinal surgery, lumbar puncture, spinal anaesthesia, placement of ventriculo-peritoneal shunts, and craniospinal trauma Typically, IH is caused by leakage of CSF through the spinal dural sac. CSF leakage is broadly divided into three commonly observed patterns: fast leaks, slow leaks, and cases in which no leak is visible despite the presence of other clinical and imaging signs of IH The main MRI finding is a characteristic diffuse pachymeningeal enhancement. Other findings include sagging of the brain, pituitary enlargement, subdural fluid collections (usually hygromas, less commonly haematomas), posterior lobe pituitary haematomas, diffuse dural enhancement of the spinal canal, spinal epidural fluid collection, distension of the spinal epidural venous plexus, and abnormal intensity around the root sleeves Treatment: Headaches usually resolve after bed rest and conservative treatment. Lying position decreases pressure in the region of CSF leakage and allows recovery at the site of leakage. Blocking the adenosine receptors with oral or intravenous caffeine and theophylline induces arterial contraction and consequently reduces intracranial blood flow and venous engorgement, which relives symptoms Intravenous or oral hydration and steroid therapy also lead to positive outcomes If this is not enough, autologous epidural blood patch may be administered intrathecally, which leads to sealing of the site of leakage with a formed clot. Surgical correction of dural tears or other meningeal defects may be performed
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!