Spontaneous intracranial hypotension associated with a dural diverticulum: a clinicoradiological correlation

Abstract

Case Presentation: A 24-year-old woman with no relevant past medical history presented with sudden-onset holocranial headache with a clearly orthostatic pattern, worsening immediately upon standing and improving approximately 2 minutes after lying down. She denied previous trauma, surgery, lumbar puncture, or any other evident precipitating factor. Given the postural nature of the headache, spontaneous intracranial hypotension was suspected. Brain magnetic resonance imaging demonstrated diffuse pachymeningeal thickening and contrast enhancement, along with intracranial venous engorgement. Further investigation with thoracic spine magnetic resonance imaging revealed an extradural lesion at T11–T12 suggestive of a dural diverticulum, in addition to a longitudinal extradural cerebrospinal fluid collection. The combination of a typical clinical presentation and characteristic neuroimaging findings established the diagnosis of spontaneous intracranial hypotension associated with a probable thoracic dural defect. Discussion: Spontaneous intracranial hypotension is an underrecognized cause of secondary headache, usually resulting from spinal cerebrospinal fluid leakage due to meningeal fragility, dural defects, or spinal CSF fistulas. Orthostatic headache is its hallmark manifestation and remains the main clinical clue to diagnosis. Brain MRI classically demonstrates diffuse pachymeningeal enhancement and venous engorgement, whereas spinal imaging may disclose extradural CSF collections and help identify the site of leakage. In this patient, the finding of a T11–T12 extradural abnormality consistent with a dural diverticulum strongly suggests an underlying structural substrate for CSF leak. This case underscores the importance of clinicoradiological correlation, particularly in young patients without prior trauma or dural instrumentation. Final Comments: This case highlights dural diverticulum as a potential structural cause of spontaneous intracranial hypotension and reinforces the diagnostic relevance of orthostatic headache. MRI of both the brain and spine is essential not only to confirm the diagnosis but also to investigate the anatomical source of leakage. Early recognition may avoid unnecessary investigations, shorten time to treatment, and facilitate appropriate management, including epidural blood patch when indicated.