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Weird case for sure where most of us would miss this. They have CNS leak institute for a reason. Not convinced LP is the standard of care here; it seems like out-pt MRI is what was needed and not always available. LP is not a benign test, and we all agonize over it; we are never reflexive about it. We all know that when a colleague or family member is sick, the standard of care is augmented, and we suffer from hindsight. LP in this case, would not make the patient feel better, probably worse
1 thing I think should have been mentioned in the differential for this patient is cerebral venous thrombosis. That is something I would have been looking for right off.
Yes CVT should be right up there but that postural exerbation to headache is pretty unusual.
I practice in a backwater called Australia. Her meds had no mpact on her dx and mx - however in Aus we have a reluctance to prescribe the OC in the presence of high blood pressure. Just saying - I would like to keep her on the job.
CVT certainly a consideration but the postural nature is the clincher. I've seen one case in my career (that I know of) and it was a near identical presentation. Kind of a fun slam dunk diagnosis (though not for the patient).
What structures do you MRI if you are thinking this is your diagnosis? do you MR the brain and the entire spine?
It should be noted that a serious complication of spontaneous idiopathic intracranial hypotension (SIIH) is subdural, occurring in 16-57% of cases . The SDH is bilateral in 90% of cases. Interestingly, we just saw such a case in our tiny 5 bed ED this week. Ref: Takahashi K, et al. Chronic Subdural Hematoma Associated with Spontaneous Intracranial Hypotension: Therapeutic Strategies and Outcomes of 55 Cases. Neurol Med Chir (Tokyo). 2016;56(2):69-76. doi: 10.2176/nmc.oa.2015-0032.
What you do matters.