Abstract We report a case of a patient aged 66 years, with spontaneous intracranial hypotension presenting initially with postural headache, complicated by subdural haematomas and followed by progressive decline of his clinical condition evolving in obtundation state, cranial nerve involvement and gaze paralysis. The patient under- went a long course of different therapeutical approaches: medical and surgical treatment, intrathecal saline infusion and epidural blood patching (EBP). Rapid and dramatic relief of the patient’s symptoms was obtained after a third lumbar EBP and he was discharged asymptomatic two weeks later. Key words Epidural blood patching • Low cerebrospinal fluid • Spontaneous intracranial hypotension Intracranial hypotension is a syndrome of low cerebrospinal fluid (CSF) pressure characterised by postural headache [1]. It may occur following lumbar puncture, craniotomy, spinal surgery or spontaneously – so-called spontaneous intracra- nial hypotension (SIH). The syndrome of SIH occurs sec- ondary to a leakage of CSF originating most often from a ruptured perineural cyst of the spine [2, 3]. This results in a reduction of intracranial CSF volume, leading to an acute or subacute onset of postural headache. Other associated symptoms of SIH include neck stiffness, nausea and vomit- ing, photophobia, anorexia, general malaise, vertigo, tinni- tus, diplopia and other cranial nerve involvement [1–8]. We present a case of complicated SIH and we discuss the appro- priate management of such a case. Case report A 66-year-old man was admitted to our department after a one-month history of headache, mainly in the occipital region, and cervical pain. The nature of his headache was continuous, and changing of his position, particularly in orthostatism, caused deterioration of his symptoms. At admission, the patient developed tendency to stupor, central left VII cranial nerve paresis, dysarthria, weakness and hypoaesthesia of the left leg and left Babinski sign. A brain computed tomography (CT) demonstrated evolving bilater- al subdural hygromas and narrowing of the ventricular sys- tem. On the following day, a brain magnetic resonance imaging (MRI) was performed and confirmed the presence of the bilateral subdural hygromas, and diffuse dural con- trast enhancement (Fig. 1a-c) suggesting intracranial hypotension. There was a partial effacement of the basal cis- terns (Fig. 1b), but there was no cerebellar tonsillar hernia- tion. MRI of the entire spine was normal, demonstrating no evidence of an obvious perineural cyst or CSF leak. Neurol Sci (2006) 27:63–66 DOI 10.1007/s10072-006-0566-2 N. Akkawi • P. Locatelli • B. Borroni • C. Agosti • A. Pezzini • R. Stefini • A. Padovani A complicated case of intracranial hypotension: diagnostic and management strategies CASE REPORT Received: 6 August 2005 / Accepted in revised form: 16 January 2006 N. Akkawi () Department of Radiology Division of Neuroimaging and Intervention University of Massachusetts Medical School 55 Lake Avenue North Worcester, MA 01655, USA e-mail: AkkawiN@ummhc.org P. Locatelli • B. Borroni • C. Agosti • A. Pezzini • A. Padovani Department of Neurological Sciences University of Brescia Brescia, Italy R. Stefini Department of Neurosurgery University of Brescia Brescia, Italy