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Spontaneous Intracranial Hypotension — SCE Neurology MCQ

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ModerateHeadache & Facial PainSpontaneous Intracranial HypotensionSCE Neurology

A 45-year-old man presents with progressive bilateral orthostatic headache (worse when upright, relieved by recumbency) without a history of lumbar puncture or spinal surgery. MRI brain with gadolinium shows diffuse pachymeningeal (dural) enhancement, sagging of the brain, and subdural collections. What is the most likely diagnosis?

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Correct answer: A — Spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) results from a spontaneous CSF leak, most commonly from the thoracic or cervicothoracic spine. Classic features include orthostatic headache and MRI showing the triad of diffuse pachymeningeal enhancement, brain sagging ('slumping midbrain'), and subdural collections. LP opening pressure is low (<6 cmH₂O). Treatment includes conservative measures, epidural blood patch, and CT-guided fibrin glue sealing of the dural defect if identified. A: Meningitis shows leptomeningeal (not pachymeningeal) enhancement. C: IIH has raised pressure and different MRI findings. D: CVST has venous thrombosis. E: Leptomeningeal carcinomatosis has leptomeningeal enhancement.

Reference: Schievink SIH Review; ABN Headache Guidelines