Spontaneous intracranial hypotension. This relatively rare condition occurs when there is leakage of cerebro-spinal fluid, in this case from a ruptured meningeal diverticula. Much like following a lumbar puncture, the loss of CSF lowers the intracranial pressure. When the patient gets up from a reclining positon the brain settles onto the floor of the cranium. Due to traction on meningeal structures as well as cranial nerves, the patient experiences pain and often some sensory – motor deficit. Depending on the structures involved there may be hypoactivity, somnolence, impaired attention, neck pain and stiffness, diplopia, nausea, vomiting, vertigo, tinnitus and impaired hearing. The condition can mimic a subarachnoid hemorrhage. Due to the greater prevalence and morbidity of CVA, this must be ruled out. Caution needs to be exercised in the imaging results. Plain film and MRI images are not contributory and may be misleading, particularly if the CFS leakage in intracranial as this could be mistaken for hemorrhage. Contrast imaging is most revealing, however, care must be taken to not over-diagnosis or misdiagnosis the condition based solely on the presence of diverticula. In this patient’s case, the rupture in the diverticula had sealed prior to the imaging, thus the lack of evidence of the errant CSF. The diagnosis is often arrived at by ruling out other options.

Question: What are some therapeutic interventions you might institute with this patient?