DOI: 10.12890/2025_005900
An unusual case of spontaneous intracranial hypotension presenting as meningoencephalitis
Authors
dias.mariana@campus.ul.pt
Keywords
Spontaneous intracranial hypotension, cerebrospinal fluid leak, orthostatic headache, meningeal enhancement, meningoencephalitisAbstract
Background: Spontaneous intracranial hypotension (SIH) is a rare, underdiagnosed cause of secondary headache due to cerebrospinal fluid (CSF) leakage. While typically presenting with orthostatic headache, atypical manifestations may mimic infectious or inflammatory diseases.
Case description: A 45-year-old man presented with acute alteration of consciousness, expressive aphasia, and nuchal rigidity after 1 month of orthostatic occipital headache. Brain magnetic resonance imaging (MRI) showed diffuse pachy- and leptomeningeal enhancement initially interpreted as infectious meningoencephalitis. Lumbar puncture revealed turbid, blood-stained CSF with elevated protein and neutrophilic pleocytosis, but microbiological and autoimmune studies were negative. Neurological symptoms improved with conservative management (bed rest, hydration, analgesia), and follow-up imaging confirmed full resolution. Retrospective neuroradiological review reclassified findings as SIH.
Conclusion: SIH can mimic infectious meningoencephalitis both clinically and in CSF appearance. Recognition of preceding orthostatic headache and characteristic MRI features is essential to avoid unnecessary antimicrobial therapy and invasive diagnostic procedures.
References
- Kranz PG, Gray L, Malinzak MD, Amrhein TJ. Spontaneous intracranial hypotension. Neuroimaging Clin N Am 2019;29:581-594. doi: 10.1016/j.nic.2019.07.006
- Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 2006;295:2286-2296. doi: 10.1001/jama.295.19.2286
- Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache 2013;53:1034-1053. doi: 10.1111/head.12149
- Chae JK, Rosen K, Zappi K, et al. Cranial and spinal cerebrospinal fluid leaks: foundations of identification and management. World Neurosurg 2024;187:288-293. doi: 10.1016/j.wneu.2024.03.111
- Jurcau MC, Jurcau A, Hogea VO, Diaconu RG. Spontaneous intracranial hypotension: case report and update on diagnosis and treatment. Diagnostics (Basel) 2024;14:881. doi: 10.3390/diagnostics14090881
- Balkan II, Albayram S, Ozaras R, Yilmaz MH, Ozbayrak M, Mete B, et al. Spontaneous intracranial hypotension syndrome may mimic aseptic meningitis. Scand J Infect Dis 2012;44:481-488. doi: 10.3109/00365548.2012.664776
- Dobrocky T, Grunder L, Breiding PS, Branca M, Limacher A, Mosimann PJ, et al. Assessing Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension With a Scoring System Based on Brain Magnetic Resonance Imaging Findings. JAMA Neurol 2019;76:580-587. doi: 10.1001/jamaneurol.2018.4921
- Bond KM, Benson JC, Cutsforth-Gregory JK, Kim DK, Diehn FE, Carr CM. Spontaneous intracranial hypotension: atypical radiologic appearances, imaging mimickers, and clinical look-alikes. AJNR Am J Neuroradiol 2020;41:1339-1347. doi: 10.3174/ajnr.A6637
- Pinto MJ, Braz L, Fonseca J, Pereira P, Trigo Barbosa P, Gomes A, et al. Protocolo de Abordagem Diagnóstica e Terapêutica da Hipotensão Intracraniana Espontânea [Guidelines for the Diagnosis and Treatment of Spontaneous Intracranial Hypotension]. Acta Med Port 2023;36:363-367. Portuguese. doi: 10.20344/amp.19432
- Shin HY. Recent update on epidural blood patch. Anesth Pain Med (Seoul) 2022;17:12-23. doi: 10.17085/apm.21113
