Update on "Treatment of orthostatic headache without intracranial hypotension: A case report" - nine years later.

BACKGROUND: In 2013, one of the authors described a 36-year-old female with orthostatic headache without documented intracranial hypotension or evidence of cerebrospinal fluid leak, despite extensive workup. Headache was unresponsive to conservative treatment since 2010, showed only transient benefit after repeated epidural blood patches while vitamin A supplementation resulted in progressive improvement. CASE: Since 2013, the patient followed a relapsing and remitting course yet relapse control became difficult after a drug induced liver injury required vitamin A discontinuation in 2017, when her headache became chronic. Greater occipital nerve blocks provided pain relief as alternative but were stopped due to the pandemic and her latest severe relapse, in late 2020, required not only restarting anaesthetic blocks and aggressive medication management, but also reassessing and treating comorbidities (obstructive sleep apnoea and major depressive disorder) with modest benefit. CONCLUSION: Orthostatic headache without intracranial hypotension is rare, with only 28 cases reported so far, all treated empirically and all treatment options revealing to be mostly ineffective. Vitamin A anecdotally appeared to be useful in our case but had to be stopped for severe side effects, so unfavourable long-term prognosis, in ours and 2/3 of the reported cases, seems to be the rule in this intriguing entity.

First-line steroid treatment for spontaneous intracranial hypotension.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a syndrome characterized by low cerebrospinal fluid (CSF) pressure and postural headaches, and affects 1 per 20,000 individuals every year. CASE REPORT: We report an otherwise healthy 38-year-old man admitted to the hospital with orthostatic headache that developed 48 h after a short-haul flight during which he sustained a neck injury due to turbulence. Neurological examination, blood analysis and computed tomography scan performed at the emergency service were normal. Brain and spine magnetic resonance imaging (MRI) showed diffuse pachymeningeal enhancement and contrast medium egress from the subarachnoid space into the epidural space at the level of C2. The patient was treated with bed rest, hydration and 1 mg/kg/day oral prednisone for 5 days, with a gradual withdrawal in the following 7 days. Complete symptomatic relief was observed after 16 days, with resolution of the pathological findings on brain and spinal MRI after 1 month, except for localized pachymeningeal enhancement. Clinical relief was maintained over time until last follow-up visit 9 months later. CONCLUSION: Successful conservative treatment barely exceeds one quarter of cases of SIH. The clinical benefits of steroids may result from several mechanisms of action, for example, improving brain oedema and inflammation, determining fluid retention, and facilitating reabsorption of the CSF from extradural space. Notwithstanding that epidural blood patch remains the most successful treatment for SIH, future studies should explore the effectiveness of steroids as first-line therapy in addition to the most commonly suggested measures of bed rest and hydration.

Intracranial Hypotension After Severe Covid-19. Case Report and Literature Review. (preprint)

Background: Despite the lack of clinical research done, new mutations of COVID-19 are travelling all over the world, and sooner or later, unexpected consequences going to be seen. In October 2020 new variant of SARV-CoV-2 (known as 20H/501.V2 or B1.351) has been found in our province (Eastern Cape), South Africa. This variant has multiple mutations in the spike protein, including K417N, E484K, N501Y. We did an extensive review of the medical literature (It is not a systematic review), looking for all publications regarding spontaneous intracranial hypotension, subdural effusions SARS-CoV-2/COVID-19. Case Presentation: We also report a case of 46-years-old-female admitted severe COVID-19 in the intensive care unit; all performed investigations confirmed the severity of the infection caused by SARS-CoV-2. Past medical history proved a chronic headache, standard routine CSF analysis, and normal MRI of the brain three months before admission.The patient recovered from the respiratory pathology and went home, but two weeks later, she developed a postural headache. We suspect spontaneous intracranial hypotension, and the CSF pressure (5.5 cm of H2O) confirmed it. CT scan of the head showed bilateral frontal subdural effusion. Conclusion: We did not find any published report related to COVID-19, subdural effusion, and intracranial hypotension. We elaborated a few comments and hypotheses to explain this process’s probable pathophysiology.