Objective:

To describe a rare case of new onset headaches demonstrating concurrent imaging findings of both low and high intracranial pressure on MRI.

Background:

Idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH) have different mechanisms of occurrence and presentation. IIH occurs when cerebrospinal fluid (CSF) cannot properly drain, while low intracranial pressure including SIH often results from a CSF leak. These conditions typically do not occur simultaneously. Both are rare, present with different symptoms, and exhibit distinct radiographic findings.

Design/Methods:

N/A

Results:

A 59-year-old man with no significant past medical history presented with new onset, severe, debilitating headaches initially requiring hospital admission. Headaches were associated with photophobia, phonophobia, nausea, blurry vision, and subjective difficulty walking without neurologic deficits on physical examination. Initial brain MRI demonstrated bilateral subdural hygromas, empty sella, and later found to also have evidence of radiographic papilledema. The headaches acutely responded to steroids including oral prednisone and IV methylprednisolone, had some improvement with triptan medications, but were refractory to many abortive therapies including CGRP inhibitors and NSAIDs. The patient was eventually treated for chronic migraines with Botox, resulting in complete resolution of his headaches, though he had persistent visual complaints and difficulty walking. Subsequent ophthalmology evaluation found bilateral papilledema, and patient was started on acetazolamide. LP revealed an opening pressure of 17 cm H₂O. Repeat brain MRI of the brain showed optic disc flattening, empty sella, diffuse pachymeningeal enhancement, and minimally decreased subdural hygromas.

Conclusions:

Radiographic findings of both IIH and SIH typically do not coincide. Patients should be promptly checked for CSF leaks and secondary intracranial hypotension. This case also highlights the importance of prompt ophthalmologic evaluation. This patient experienced resolution of his IIH-related headache with Botox but subsequently developed a low intracranial pressure headache that required tapering of the acetazolamide.