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Case Reports
. 2014 Feb 21:5:22.
doi: 10.4103/2152-7806.127756. eCollection 2014.

Thunderclap headache: It is always sub-arachnoid hemorrhage. Is it? - A case report and Review

Raghunath Aladakatti  1 , Laxmikant B Sannakki  1 , Peter Y Cai  2 , Roselle Derequito  2
Affiliations
Case Reports

Thunderclap headache: It is always sub-arachnoid hemorrhage. Is it? - A case report and Review

Raghunath Aladakatti et al. Surg Neurol Int. .

Abstract

Background: Spontaneous intracranial hypotension (SIH) is one of the relatively misdiagnosed pathophysiological entities by virtue of its presentation. SIH is a condition involving reduced intracranial pressure usually secondary to dural tear. There is recent increase in reporting of its varied presentation in literature. Critical care physicians and neurosurgeons are recognizing it in higher numbers than before. SIH is characterized by sudden onset of orthostatic headache and may be associated with neck stiffness, nausea, vomiting, tinnitus, deafness, and cognitive abnormalities. Since its imaging characteristics resemble classic subdural hematoma from other causes wrong diagnosis and intervention might have devastating outcome.

Case description: Here we discuss a case presented to us with severe headache of sudden onset without any associated problems. Patient was initially being treated as sinusitis and later diagnosed as bilateral subdural hematoma and surgical intervention was being considered. Thorough history taking and physical examination lead to strong suspicion of intracranial hypotension (IH) and patient showed dramatic improvement with epidural blood patch.

Conclusion: IH is a commonly misdiagnosed entity. A high index of suspicion is required for timely diagnosis, in order to minimize unwanted therapeutic interventions that can worsen the patient's condition and to help initiate early and simple interventions.

Keywords: Diagnosis; hypotension; intracranial; presentation; spontaneous.

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Figures

Figure 1
Figure 1
MRI Brain when patient presented with symptoms: T2 (a) and T1 (b) axial sequence of brain MRI show bilateral subdural collection (arrows) of hematoma and slit-like ventricles
Figure 2
Figure 2
MRI Brain when patient presented with symptoms: T1 sagittal sequence of brain MRI show reduced mammillary body and pontine distance due to the descent of the mammillary body (arrow), crowding of posterior fossa due to brainstem descent, descent of cerebellar tonsils, sagging of tuber cinereum, inferior displacement of splenium and descent of the fastigium of the fourth ventricle
Figure 3
Figure 3
Postprocedure CT head: Noncontrast CT head 3 months after the blood patch shows complete resolution of the subdural hematoma
See this image and copyright information in PMC

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