Thunderclap headache revealing dural tears with symptomatic intracranial hypotension: Report of two cases

Abstract

Cerebrospinal fluid (CSF) leakage is considered the cause of spontaneous intracranial hypotension (SIH), an important etiology for new daily persistent headaches and a potentially life-threatening condition. Minor traumatic events rarely lead to CSF leakage, contrasting with iatrogenic interventions such as a lumbar puncture or spinal surgery, which are commonly complicated by dural tears. Most meningeal lesions are found in the cervicothoracic region, followed by the thoracic region, and rarely in the lumbar region, and extremely rarely in the sacral region. We describe two patients admitted to our hospital for severe headaches aggravated in the orthostatic position, with a recent history of minor trauma and sustained physical effort, respectively. In the first case, a bone fragment pierced an incidental congenital meningocele creating a dural fistula. An extensive extradural CSF collection, spanning the cervicothoracic region (C4-T10), was described in the second case. In both patients, the clinical evolution was favorable under conservative treatment.

Keywords: CSF leakage; case report; intracranial hypotension; post-traumatic dural tear; sacral fracture; sacral osseous fragment; severe headache; thunderclap headache.

Figure 1

Axial MRI contrast-enhanced T1 images: similar sections at the moment of diagnosis (A–C), and, respectively, 5 months later (D–F). Initially, the MRI revealed diffuse, relatively uniform thickening and enhancement of the pachymeninges and tentorium, without pathological enhancement [(A, B)—yellow arrows] and an enlarged pituitary gland with a cranially convex superior border [(C)—yellow arrow]. Also, the dural venous sinuses and cortical veins were initially slightly engorged. Five months later the images showed normalization of the pachymeninges (D, E) and a reduction of the craniocaudal diameter of the hypophysis (F).

Figure 2

(A–C) Sagittal, axial, and coronal computed tomography, and (D–F) MRI images at approximately the same anatomical plane of section. (D–F) Voluminous meningoceles visible on the MRI images. (B) The posterior dysraphism is clearly visible on the CT transversal section. (C) The fracture line is best visualized in the coronal plane (small and large yellow arrows), with a bone fragment protruding into the sacral canal on the left side [(A–F)—large yellow arrows]. (D, E) The bone fragment clearly imprints the left sacral meningocele and appears to pierce it (F).

Figure 3

(A) Coronal MRI contrast-enhanced T1 image revealing slight diffuse thickening of the cerebellar tentorium and pericerebral pachymeninges, especially bilateral paramedian parietal [(A)—yellow arrows]. (B) Sagittal MRI contrast-enhanced T1 showing an enlarged pituitary gland with superior border cranially convex [(B)—yellow arrow]. (C) Sagittal spine MRI showing a posterior cervicothoracic epidural collection with fluid signal, extended craniocaudal from the C4 to T10, with a maximum thickness of about 5 mm in the thoracic region. The thoracic spinal cord is anteriorly displaced but not compressed. (D) Transversal MRI section of the thoracic spine (T6) showing the posterior epidural collection that displaces the spinal content anteriorly [(D)—yellow arrow].

Figure 4

(A, B, D, E) 3D reconstruction (13) of the sacrum from the CT scan images. (C, F) A spinal canal mold from the CSF signal on the MRI images. The left S2 radicular cyst is visible above the meningoceles. (A) Posterior view showing the dysraphism at the level of the bone. [(A)—small arrowheads] The fracture line is partially visible. [(B)—small arrowheads] Posterior oblique view of the pelvic surface of the sacrum showing the transverse fracture at S4 and [(B)—black arrow] the bone fragment that protrudes into the spinal canal. (C) The spinal canal ends with two large meningoceles at the S3 level. (D) Interior view of the sacral canal from the midline, the black arrow points to the protruding bone fragment. [(E)—small arrowheads] Interior view of the posterior wall of the sacral canal, showing the line of fracture and [(E)—black arrow] the protruding fragment. (F) Oblique posterior view showing the imprint of the fractured bone fragment on the left meningocele.