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*Only for medical professionals to read and refer to thousands of headaches, and the first one to clarify the cause! Without further ado, let's take a look at this case, a 66-year-old male patient who was admitted to the hospital due to headaches for 1 year
.
One year ago, the patient started to have unprovoked daily persistent headache.
The headache was mostly manifested as bilateral pressure and tightness, and the degree was mild to moderate, accompanied by photophobia and fear
.
No nausea, vomiting, dizziness, dizziness and unsteady walking, no fever, disturbance of consciousness,
etc.
The headache is not significantly related to mood, season, weather (women also need to consider the impact of menstruation)
.
The patient had been treated with migraine prophylaxis and nonsteroidal anti-inflammatory drugs, with no relief from headache
.
The patient's neurological examination, including fundoscopy, was normal
.
Looking at this case initially, what is your diagnosis? ■ Based on this case, I believe your preferred diagnosis must be New Onset Daily Persistent Headache (NDPH)
.
NDPH is a specific type of chronic daily headache that falls under the category of "benign or self-limiting" headaches
.
Most of the patients present with sudden headache, which persists without relief.
The patient can always remember the exact start date of the headache, and despite receiving active treatment, it still persists for several years or even decades
.
At present, the pathophysiology of NDPH is still poorly understood, and some scholars have suggested that it may be related to the stimulation of inflammatory factors secondary to central nervous system inflammation, or it may be secondary to infectious factors (especially EB virus infection)
.
Understanding the causes of primary and secondary headaches is critical to the diagnosis and differential diagnosis of NDPH
.
Table 1 summarizes the comprehensive differential diagnosis of NDPH, including clinical clues and neuroimaging features
.
Table 1.
Clinical diagnostic clues and neuroimaging features of headache (zoom in for a clear view) Careful history is very important for headache patients, especially to pay attention to some classic "red flag signs" Time must not be missed
.
Table 2 lists the important "red flags" in headache patients
.
Table 2 Further medical history inquiry and auxiliary examination for the important "red flag sign" in headache patients We further inquired the patient's medical history according to the above "red flag sign" of the headache medical history.
We found that the patient's headache changed with the change of position.
The headache is aggravated and relieved in the supine position, and the patient can induce severe headache while doing the Valsalva maneuver, which lasts for up to 1 hour and improves within 15-30 minutes after bed rest
.
■ MRI of the patient's brain Figure 1 MRI of the patient's brain
.
(A) Sagittal T1-weighted image shows brain ptosis during spontaneous intracranial hypotension
.
The anterior cistern narrows (arrow)
.
The optic chiasm and optic tract are displaced downward (arrows)
.
(B) Axial T1-weighted contrast-enhanced imaging shows diffuse dural enhancement (arrows)
.
(C) Coronal T1-weighted imaging shows diffuse dural enhancement (arrows) and bilateral subdural effusions (arrows)
.
■ Patient Myelography (DSM) Figure 2 Patient Myelography
.
DSM (AC) shows marked contrast leakage into the right paravertebral T7-T8 region (arrows), indicating a slow-flowing spinal cerebrospinal fluid (CSF) leak
.
The final diagnosis of the patient combined with further medical history and imaging examinations, we concluded that the final diagnosis of the patient was Spontaneous Intracranial Hypotension (SIH) caused by cerebrospinal fluid leakage
.
Discussion Spontaneous Intracranial Hypotension (SIH) was first described by German neurosurgeon Schaltenbrand in 1938, so it is also called Schaltenbrand syndrome
.
The syndrome is rare clinically, more women than men, and the age of onset is more than 20-40 years old
.
The diagnosis of SIH is mainly based on the typical clinical symptoms of orthostatic headache (appearance or aggravation in the upright position, reduction or disappearance in the supine position), and the cerebrospinal fluid pressure measured by lumbar puncture is lower than 60mm H20
.
The possible pathogenesis of SHI is that the production of cerebrospinal fluid is too low, the absorption of cerebrospinal fluid is excessive, and the small tear of the brain (spinal) membrane causes the leakage of cerebrospinal fluid
.
The imaging manifestations of SIH include brain CT scan: some patients may find subdural effusion or hemorrhage, and increased cerebellar density
.
Brain MRI: T2 phase showed dural thickening and widening of the superior sagittal sinus, T1 enhanced phase showed extensive dural enhancement and widened superior sagittal sinus and transverse sinus, T1 phase sagittal showed brain subsidence, cerebral peduncle cruciate cistern disappeared, The bridge pool becomes smaller, the pituitary gland enlarges,
etc.
CT myelography: can show changes such as dural tears or diverticula
.
Figure 3 Typical SIH imaging findingsFigure 4 Typical SIH imaging findings The treatment of SIH is mainly symptomatic treatment and treatment based on the cause
.
Symptomatic treatment mainly includes: bed rest, drinking plenty of water, intravenous rehydration, oral caffeine, theophylline, oral low-dose hormones,
etc.
If there is no significant relief after symptomatic treatment for 1 week, autologous venous epidural blood sticking therapy (slowly inject 20ml of autologous venous blood into the epidural), or CT-guided epidural fibrin repair, or surgical treatment ( The meningeal diverticulum is ligated with suture or aneurysm clip, the dural tear is sutured, and the epidural space is wrapped with gelatin or collagen fibers)
.
References: [1] Duvall JR et al.
Clinical Reasoning: An underrecognized etiology of new daily persistent headache.
Neurology 2020 01; 07; 941(1).
[2] Arora R et al.
Spontaneous intracranial hypotension.
J Assoc Physicians India .
2014 Mar;62(3):281-3.
[3]Han Shunchang, Pu Chuanqiang
.
Imaging features of spontaneous intracranial hypotension syndrome, Chinese Journal of Medical Imaging, Vol.
14, No.
2, 2006
.
First publication of the text: Neurology Channel of the Medical Community Author of this article: Liny Editor in charge: Mr.
Lu Li The medical community strives to be accurate and reliable when the published content is approved, but it does not regard the timeliness of the published content and the citations (if any) of the published content.
Accuracy and completeness, etc.
, make any promises and guarantees, and do not assume any responsibility for the outdated content, the possible inaccuracy or incompleteness of the cited materials,
etc.
Relevant parties are requested to check separately when adopting or using it as a basis for decision-making
.
Contribution/reprint/business cooperation: yxjsjbx@yxj.
org.
cn
.
One year ago, the patient started to have unprovoked daily persistent headache.
The headache was mostly manifested as bilateral pressure and tightness, and the degree was mild to moderate, accompanied by photophobia and fear
.
No nausea, vomiting, dizziness, dizziness and unsteady walking, no fever, disturbance of consciousness,
etc.
The headache is not significantly related to mood, season, weather (women also need to consider the impact of menstruation)
.
The patient had been treated with migraine prophylaxis and nonsteroidal anti-inflammatory drugs, with no relief from headache
.
The patient's neurological examination, including fundoscopy, was normal
.
Looking at this case initially, what is your diagnosis? ■ Based on this case, I believe your preferred diagnosis must be New Onset Daily Persistent Headache (NDPH)
.
NDPH is a specific type of chronic daily headache that falls under the category of "benign or self-limiting" headaches
.
Most of the patients present with sudden headache, which persists without relief.
The patient can always remember the exact start date of the headache, and despite receiving active treatment, it still persists for several years or even decades
.
At present, the pathophysiology of NDPH is still poorly understood, and some scholars have suggested that it may be related to the stimulation of inflammatory factors secondary to central nervous system inflammation, or it may be secondary to infectious factors (especially EB virus infection)
.
Understanding the causes of primary and secondary headaches is critical to the diagnosis and differential diagnosis of NDPH
.
Table 1 summarizes the comprehensive differential diagnosis of NDPH, including clinical clues and neuroimaging features
.
Table 1.
Clinical diagnostic clues and neuroimaging features of headache (zoom in for a clear view) Careful history is very important for headache patients, especially to pay attention to some classic "red flag signs" Time must not be missed
.
Table 2 lists the important "red flags" in headache patients
.
Table 2 Further medical history inquiry and auxiliary examination for the important "red flag sign" in headache patients We further inquired the patient's medical history according to the above "red flag sign" of the headache medical history.
We found that the patient's headache changed with the change of position.
The headache is aggravated and relieved in the supine position, and the patient can induce severe headache while doing the Valsalva maneuver, which lasts for up to 1 hour and improves within 15-30 minutes after bed rest
.
■ MRI of the patient's brain Figure 1 MRI of the patient's brain
.
(A) Sagittal T1-weighted image shows brain ptosis during spontaneous intracranial hypotension
.
The anterior cistern narrows (arrow)
.
The optic chiasm and optic tract are displaced downward (arrows)
.
(B) Axial T1-weighted contrast-enhanced imaging shows diffuse dural enhancement (arrows)
.
(C) Coronal T1-weighted imaging shows diffuse dural enhancement (arrows) and bilateral subdural effusions (arrows)
.
■ Patient Myelography (DSM) Figure 2 Patient Myelography
.
DSM (AC) shows marked contrast leakage into the right paravertebral T7-T8 region (arrows), indicating a slow-flowing spinal cerebrospinal fluid (CSF) leak
.
The final diagnosis of the patient combined with further medical history and imaging examinations, we concluded that the final diagnosis of the patient was Spontaneous Intracranial Hypotension (SIH) caused by cerebrospinal fluid leakage
.
Discussion Spontaneous Intracranial Hypotension (SIH) was first described by German neurosurgeon Schaltenbrand in 1938, so it is also called Schaltenbrand syndrome
.
The syndrome is rare clinically, more women than men, and the age of onset is more than 20-40 years old
.
The diagnosis of SIH is mainly based on the typical clinical symptoms of orthostatic headache (appearance or aggravation in the upright position, reduction or disappearance in the supine position), and the cerebrospinal fluid pressure measured by lumbar puncture is lower than 60mm H20
.
The possible pathogenesis of SHI is that the production of cerebrospinal fluid is too low, the absorption of cerebrospinal fluid is excessive, and the small tear of the brain (spinal) membrane causes the leakage of cerebrospinal fluid
.
The imaging manifestations of SIH include brain CT scan: some patients may find subdural effusion or hemorrhage, and increased cerebellar density
.
Brain MRI: T2 phase showed dural thickening and widening of the superior sagittal sinus, T1 enhanced phase showed extensive dural enhancement and widened superior sagittal sinus and transverse sinus, T1 phase sagittal showed brain subsidence, cerebral peduncle cruciate cistern disappeared, The bridge pool becomes smaller, the pituitary gland enlarges,
etc.
CT myelography: can show changes such as dural tears or diverticula
.
Figure 3 Typical SIH imaging findingsFigure 4 Typical SIH imaging findings The treatment of SIH is mainly symptomatic treatment and treatment based on the cause
.
Symptomatic treatment mainly includes: bed rest, drinking plenty of water, intravenous rehydration, oral caffeine, theophylline, oral low-dose hormones,
etc.
If there is no significant relief after symptomatic treatment for 1 week, autologous venous epidural blood sticking therapy (slowly inject 20ml of autologous venous blood into the epidural), or CT-guided epidural fibrin repair, or surgical treatment ( The meningeal diverticulum is ligated with suture or aneurysm clip, the dural tear is sutured, and the epidural space is wrapped with gelatin or collagen fibers)
.
References: [1] Duvall JR et al.
Clinical Reasoning: An underrecognized etiology of new daily persistent headache.
Neurology 2020 01; 07; 941(1).
[2] Arora R et al.
Spontaneous intracranial hypotension.
J Assoc Physicians India .
2014 Mar;62(3):281-3.
[3]Han Shunchang, Pu Chuanqiang
.
Imaging features of spontaneous intracranial hypotension syndrome, Chinese Journal of Medical Imaging, Vol.
14, No.
2, 2006
.
First publication of the text: Neurology Channel of the Medical Community Author of this article: Liny Editor in charge: Mr.
Lu Li The medical community strives to be accurate and reliable when the published content is approved, but it does not regard the timeliness of the published content and the citations (if any) of the published content.
Accuracy and completeness, etc.
, make any promises and guarantees, and do not assume any responsibility for the outdated content, the possible inaccuracy or incompleteness of the cited materials,
etc.
Relevant parties are requested to check separately when adopting or using it as a basis for decision-making
.
Contribution/reprint/business cooperation: yxjsjbx@yxj.
org.
cn
