A patient presented with sudden onset of postural headaches that improved with recumbency associated with nausea, vomit, photophobia and phonophobia of 5 days of evolution followed by binocular horizontal diplopia at distance and in left gaze. Patient denied recent weight gain or trauma, use of vitamin A derivatives, steroids, antibiotics, or oral contraceptive pills. Physical exam revealed a BMI of 19.3, excellent uncorrected vision in both eyes, stereopsis of 40 seconds of arc, normal color vision, and pupillary exam. A mild limitation to abduction in the left eye was identified with a small non-comitant esotropia worse in left gaze consistent with a left abducens palsy. Slit lamp and posterior segment exam were unremarkable. Brain magnetic resonance imaging (MRI) with and without intravenous contrast revealed diffuse smooth dural enhancement, mild brain sagging, a prominent pituitary gland and small bilateral subdural effusions. Patient was diagnosed with spontaneous intracranial hypotension (SIH) based on the typical postural headaches and presence of characteristic findings in brain MRI. The patient was started in conservative management with high doses of caffeine and aggressive hydration and referred to neurosurgery for evaluation.
Presentation Date: 08/19/2021
Issue Date: 03/25/2022