Man With Headache

A 34-year-old man presented to the emergency department with 1 day of sudden-onset headache after chiropractic cervical spinal manipulation. He had nausea with a postural headache that was relieved by lying flat. He had a nonfocal neurologic examination and underwent computed tomography (CT) angiography of the head and neck, which demonstrated no vascular dissection or subarachnoid hemorrhage. Neurology was consulted and recommended magnetic resonance imaging (MRI) of the brain and cervical spine (Figure 1, Figure 2, Figure 3).Figure 2Axial T2 MRI at the level of C7. Enhancing cerebrospinal fluid isodense fluid (arrows) is now present circumferentially around the dural sac.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Sagittal brain MRI. Intracranial hypotension is indicated by low-lying cerebellar tonsils (arrow) and prominent dural venous sinuses.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Intracranial hypotension as a result of cerebrospinal fluid leak. MRI identified a cerebrospinal fluid leak with isodense fluid in the epidural space beginning at C4 (Figures 1 and 2) and low-lying cerebellar tonsils indicative of intracranial hypotension (Figure 3). The patient underwent an epidural blood patch for persistent headache. CT myelogram images from this procedure demonstrated a ventral dural defect at C7 with early contrast opacification of the extradural space (Figure 4). Chiropractic manipulation has been associated with vascular dissection, stroke, epidural hematoma, central cord syndrome, atlantoaxial dislocation, and pathologic fractures.1Ernst E. Adverse effects of spinal manipulation: a systematic review.J R Soc Med. 2007; 100: 330-338Crossref PubMed Scopus (166) Google Scholar A handful of case reports have described intracranial hypotension following manipulation.2Kusnezov N.A. Velani S.A. Lu D.C. Cerebrospinal fluid leak secondary to chiropractic manipulation.Surg Neurol Int. 2013; 4: S118-S120PubMed Google Scholar,3Mathews M.K. Frohman L. Lee H.J. et al.Spinal fluid leak after chiropractic manipulation of the cervical spine.Arch Ophthalmol. 2006; 124: 283Crossref PubMed Scopus (13) Google Scholar This condition is frequently a result of traumatic dural tears and may present as an orthostatic headache associated with nausea and neck stiffness.2Kusnezov N.A. Velani S.A. Lu D.C. Cerebrospinal fluid leak secondary to chiropractic manipulation.Surg Neurol Int. 2013; 4: S118-S120PubMed Google Scholar, 3Mathews M.K. Frohman L. Lee H.J. et al.Spinal fluid leak after chiropractic manipulation of the cervical spine.Arch Ophthalmol. 2006; 124: 283Crossref PubMed Scopus (13) Google Scholar, 4Schievink W.I. Louy C. Precipitating factors of spontaneous spinal CSF leaks and intracranial hypotension.Neurology. 2007; 69: 700-702Crossref PubMed Scopus (39) Google Scholar Brain MRI is diagnostic of intracranial hypotension in approximately 80% of cases; CT lacks sensitivity.5Chan S.M. Chodakiewitz Y.G. Maya M.M. et al.Intracranial hypotension and cerebrospinal fluid leak.Neuroimaging Clin N Am. 2019; 29: 213-226Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Spinal MRI and CT myelogram offer confirmation and localization of a cerebrospinal fluid leak.2Kusnezov N.A. Velani S.A. Lu D.C. Cerebrospinal fluid leak secondary to chiropractic manipulation.Surg Neurol Int. 2013; 4: S118-S120PubMed Google Scholar,3Mathews M.K. Frohman L. Lee H.J. et al.Spinal fluid leak after chiropractic manipulation of the cervical spine.Arch Ophthalmol. 2006; 124: 283Crossref PubMed Scopus (13) Google Scholar,5Chan S.M. Chodakiewitz Y.G. Maya M.M. et al.Intracranial hypotension and cerebrospinal fluid leak.Neuroimaging Clin N Am. 2019; 29: 213-226Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Although an epidural blood patch is frequently required, a proportion of dural tears resolve spontaneously. Initial conservative management with hydration, bed rest, and caffeine is reasonable.5Chan S.M. Chodakiewitz Y.G. Maya M.M. et al.Intracranial hypotension and cerebrospinal fluid leak.Neuroimaging Clin N Am. 2019; 29: 213-226Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar