Spontaneous intracranial hypotension with extensive epidural fluid collection in the spine: a case improved with steroid therapy

A case of spontaneous intracranial hypotension (SIH) with extensive epidural fluid collection in the spine is described. Although epidural blood patch (EBP) was not performed, treatment with glucocorticoid resulted in clinical and radiological improvement. A previously healthy 45-year-old woman developed severe generalized headache that was partially relieved by lying flat (day 1). On day 5, she consulted our clinic. Neurological examination was unremarkable. Lumbar cerebrospinal fluid (CSF) pressure was too low to be measured. On day 11, cranial MRI with gadolinium-DTPA infusion demonstrated diffuse thickening and enhancement of the pachymeninges. Radionuclide cisternography demonstrated early accumulation of the tracer in the bladder but there was no sign of CSF leakage. Spinal MRI showed epidural fluid collection extending from the upper cervical through lumbar levels, suggesting that lumbar EBP might be less effective. Three weeks of bed-rest and oral hydration failed to relieve the headache. Oral prednisolone 40 mg was started on day 23, and the headache improved within two days. Cranial MRI on day 88 showed complete resolution of the previous abnormalities. Spinal MRI on day 118 demonstrated almost complete disappearance of epidural fluid collection. The present case suggests that glucocorticoid therapy can be a useful treatment option for SIH.