Intracranial Hypotension Mimicking Cervical Radiculopathy

Introduction

Intracranial hypotension (IH) typically presents with an orthostatic headache and is characterized by distinct abnormalities on the brain and spine MRI. Most commonly a small tear or defect in the spinal dural sac is the underlying lesion that results in a CSF leakage and IH.1–3

Abstract

Intracranial hypotension typically presents with an orthostatic headache, often with one or more of the following symptoms: nausea, vomiting, change in hearing, diplopia, blurred vision, and neck pain. Rarely it presents with upper limb numbness, paresthesias, and aches. We report the case of a 35-year-old man who—after a polytrauma car accident—had an orthostatic headache, diplopia, and bilateral muffled hearing. After 7 months he started presenting progressive weakness of the right upper limb and atrophy mainly of the right deltoid, biceps and triceps muscles, and milder weakness of the right forearm and left arm muscles without pain or loss of sensation. A neurophysiological examination showed marked neurogenic impairment in muscles of C5–C6 and C7 bilaterally suggestive of motor cervical radiculopathy. A spine MRI revealed an epidural CSF collection at the cervico-thoracic junction and a CT myelography revealed an extravasation of contrast medium at the same level. The man was diagnosed with an intracranial hypotension form of cervical CSF leakage by dural tear and a lumbar autologous epidural blood patch was performed with a progressive, albeit partial, improvement of the motor impairment during the following 24 months. Pure motor cervical radiculopathy with spinal amyotrophy is yet another mode of the still broadening clinical presentation of intracranial hypotension syndrome.

Keywords

Headache, intracranial hypotension, cervical radiculopathy, focal spinal amyotrophy, cerebrospinal fluid leak, epidural blood patch