Case report: spontaneous intracranial hypotension in association with the presence of a false localizing C1-C2 cerebrospinal fluid leak

BackgroundSpontaneous intracranial hypotension is an increasingly recognized cause of new-onset, daily, persistent headaches. Although these headaches are similar to post–lumbar puncture headaches, characteristic differences include intracranial pachymeningeal enhancement, subdural fluid collections, and downward displacement of the brain. The identification of upper cervical epidural fluid collections as a false localizing sign in patients with SIH has provided significant insight into the selection of management options.Case DescriptionWe review a case of a 57-year-old woman who presented to our institution with progressive orthostatic headaches relieved by recumbency. The patient had no recent history of lumbar puncture, spinal, or intracranial procedure. The patient isolated the onset of symptoms to 3 weeks prior, when she was lifting heavy items in her home, and was diagnosed with SIH. Subsequently, she was found to have a C1-C2 epidural fluid collection. After much diagnostic consideration and review of the literature, the collection was defined as a false localizing sign; and the patient eventually underwent a lumbar EBP with complete resolution of her symptoms.ConclusionsUpper cervical fluid collections in patients with SIH often represent a false localizing sign. Conservative management should be instituted; and if unsuccessful, a lumbar EBP should be performed. It is important to note that C1-C2 fluid accumulations may not provide the actual leak site in patients presenting with SIH. This understanding prevents therapy from being unintentionally directed at C1-C2.