Spontaneous intracranial hypotension in a patient with meningeal diverticula: a case report

Objective: spontaneous intracranial hypotension (SIH) can sometime represent a puzzling clinical condition due to missing causal factors and poor response to treatment. Here we describe a SIH case where cerebrospinal fluid (CSF) leaks follow to the uncommon cause of meningeal diverticula[1]. Materials: a 54-years-old-woman who works as a caregiver came to our attention for a symptomatology characterized by heavy headache localized on the vertex that started after long lasting upright position and that improved with rest. During last two months the pain has begun costant, associated with vertigo and non responsive to rest or symptomatic drugs. Methods: the patient was admitted to our Unit and remained for 9 days. During such period she underwent medical therapy with intravenous hydratation, 5% glucose solution and 8 mg of desametasone per day. We performed a cerebral CT scan and cerebral and cervicodorsal contrast-enhanced magnetic resonance imaging (MRI). Moreover, the patient underwent a Neuro-surgical consult. Results: CT scan showed intracranial hypotension suggestive signs and the diagnosis was confirmed by cerebral MRI scan, showing pachimeningeal thickening and contrast enhancement and slight caudal sliding of the cerebellar tonsils and diencephalic structures, associated to smaller ventricles. Cervico-dorsal MRI scan revealed the causal factor, highlighting the presence of 5 meningeal diverticula turning outwards at the level of right D9- D10 and D11-D12 and left D8-D9, D9-D10 and D10-D11 intervertebral foramen (the biggest 12 mm). The patient response to medical therapy was good and led to symptoms regression, making not necessary other therapeutic approaches, such as epidural blood patch or surgical intervention. One month after discharge the patient referred no headache, but sporadic vertigo that she controlled using antivertiginous drugs. Discussion: spontaneous intracranial hypotension has several causes, one of them is represented by cerebrospinal leaks. Meningeal diverticula represent a possible, even if very rare, cause of cerebrospinal leaks and, in our case, such link was probably at the origin of our patient symptoms and imaging signs. Medical treatment succeded in soothing patient’s headache and vertigo, so, in future, it will be useful to reconsider the need for surgical intervention in patients with meningeal diverticula. Conclusions: Meningeal diverticula, even if rare, are possible causes of SIH and medical treatment could be effective in such cases, since surgery is not always needed.