Chronic intracranial pachymeningopathy due to persistent dura leakage following diagnostic lumbar puncture

A 38-year old patient with multiple sclerosis developed persisting orthostatic headache following a diagnostic lumbar puncture (LP). The LP was prompted by an acute insensibility of the left side to pain and temperature from dermatome Th6. Six days after LP, cranial magnetic resonance imaging (MRI) revealed diffuse pachymeningeal thickening and gadolinium enhancement, which increased in magnitude over the next months. Based on the typical headache and the diffuse pachymeningopathy, we made the diagnosis of chronic intracranial hypotension caused by a persistent cerebrospinal fluid (CSF) leak following LP. Six months after LP, headache resolved in response to an epidural blood patch. Clinical improvement was paralleled by a decrease in pachymeningeal thickening and gadolinium enhancement after epidural blood patch. Orthostatic headache recurred two months later when the patient lifted a heavy basket. Accordingly, repeated MRI demonstrated an increase in pachymeningeal abnormalities. Eleven months after initial LP, CT myelography revealed a persistent lumbar leakage of CSF at L4/5 level. The present case report demonstrates that chronic symptomatic CSF leakage can persist for months after LP. Most patients with post-lumbar persistent intracranial hypotension due to CSF leakage show diffuse dural thickening and gadolinium enhancement. The amount of diffuse pachymeningeal gadolinium enhancement appears to parallel the severity of headache. Thus, repeated MRI is useful to establish the diagnosis and to monitor the course of post-lumbar intracranial hypotension.     «

A 38-year old patient with multiple sclerosis developed persisting orthostatic headache following a diagnostic lumbar puncture (LP). The LP was prompted by an acute insensibility of the left side to pain and temperature from dermatome Th6. Six days after LP, cranial magnetic resonance imaging (MRI) revealed diffuse pachymeningeal thickening and gadolinium enhancement, which increased in magnitude over the next months. Based on the typical headache and the diffuse pachymeningopathy, we made the d...     »