Intracranial hypotension with parkinsonism, ataxia, and bulbar weakness

Objective: To describe a case of spontaneous intracranial hypotension with a previously unreported constellation of presenting features. Design: Case report. Setting: Tertiary care center. Main Outcome and Results: We describe a patient with intracranial hypotensi on who presented with a parkinsonian syndrome and later development of atax ia and prominent bulbar symptomatology. Headache was not a feature of her i nitial presentation and was only reported after repeated questioning during later evaluations. Magnetic resonance imaging of the patient's head reveal ed findings characteristic of intracranial hypotension. An [F-18]fluoro-m-t yrosine positron emission tomographic scan showed normal striatal activity, suggesting intact presynaptic nigrostriatal function. Opening pressure on lumbar puncture was reduced at 40 mm H2O. A source of cerebrospinal fluid l eakage was not identified on nuclear cisternography and the patient underwe nt lumbar epidural blood patching, which resulted in complete resolution of her signs and symptoms as well as in a marked improvement in her imaging f indings. Conclusions: The clinical spectrum of intracranial hypotension can be broad ened to include parkinsonism, cerebellar ataxia, and prominent bulbar dysfu nction. As with more common manifestations of the disorder, these features may resolve after appropriate treatment.