European Journal of Radiology Extra 69 (2009) e41–e44 Angiographic findings in spontaneous intracranial hypotension mimicking subarachnoid hemorrhage Sait Albayram a , Mustafa Onur Ulu b,* , Mehmet Yasar Kaynar b , Naci Kocer a , Civan Islak a a Istanbul University, Cerrahpasa Medical Faculty, Department of Radiology, Division of Neuroradiology, Istanbul, Turkey b Istanbul University, Cerrahpasa Medical Faculty, Department of Neurosurgery, 34300 Kocamustafapasa, Istanbul, Turkey Received 6 June 2008; accepted 2 July 2008 Abstract Due to a wide variety of symptoms in the clinical presentation, immediate diagnosis of spontaneous intracranial hypotension (SIH) can be challenging. The headache may be very severe and the clinical picture can be first interpreted as subarachnoid hemorrhage (SAH) in the existence of supportive diagnostic findings. Moreover, there is insufficient data in the literature regarding the angiographic findings in SIH. We report on an unusual case of 51-year-old female, who presented in the typical setting of SAH and later diagnosed as SIH. We define additional angiographic findings in SIH with special attention to the craniocervical region. The importance of considering SIH in the differential diagnosis of SAH is also stressed. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Digital substraction angiography; Diagnosis; Spontaneous intracranial hypotension; Subarachnoid hemorrhage; Treatment 1. Introduction Although spontaneous intracranial hypotension (SIH) was first described in 1938 [1], more frequent observation of this pathology has only been reported during the past two decades. This is mostly due to the unusually varied spectrum of clinical and radiographic manifestations of this pathology. The diagnos- tic imaging in SIH includes contrasted MRI, CT cisternography and radionuclide cisternography [2]. Only a few reports are available in the literature describing the angiographic findings in SIH [3–5]. We define additional angiographic findings in SIH with particular attention to craniocervical region in a patient who presented in the typical clinical setting of subarachnoid hemorrhage (SAH). 2. Case report This 51-year-old previously healthy female experienced a sudden onset of severe thunderclap headache and was admit- ted to the ER of a local hospital on the next day. Her cranial * Corresponding author. Tel.: +90 212 414 3000x22724; fax: +90 212 414 3167. E-mail addresses: dronurulu@hotmail.com, dronurulu@gmail.com, onurulu@istanbul.edu.tr (M.O. Ulu). CT revealed no evidence of a pathology, including SAH. How- ever, a lumbar puncture was reported to yield high numbers of red blood cells in all tubes and the findings of xanthochro- mia. She was diagnosed as SAH and was referred to our clinic for further evaluation and treatment. Upon admission she had a Glasgow Coma Scale score of 15 and was neurologically intact except for mild neck stiffness. The cerebral 3D DSA performed in our clinic revealed two, 3–4-mm paraophthalmic aneurysms (Fig. 1). As the dimensions of both aneurysm were small and the pattern and the morphology of both were not consistent with any rupture, embolization was not performed. While evaluating the angiographic projections in the venous phase, prominence of medullary and cortical veins, suboccipital sinus and its con- nections, diploic veins, cavernous sinus and pterygoid plexus were identified. Moreover, the normal venous drainage pattern in supine position towards the jugular veins was shifted par- tially towards the craniovertebral junction (Fig. 2A–C). Further questioning the patient’s history revealed that her headache was orthostatic in nature. SIH was considered in the differential diag- nosis and a contrast-enhanced cranial MRI was performed which revealed dural thickening and contrast enhancement (Fig. 3). Subsequently a CT cisternography is planned. The opening CSF pressure was low (∼30 mm H 2 O) and a slow CSF leakage was demonstrated at the upper dorsal area level (Fig. 4). She was treated with the injection of 35 cm 3 autologous blood patch. Her 1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.07.009