Chronic intracranial pachymeningopathy due to persistent dura leakage following diagnostic lumbar puncture

A 38-year old patient with multiple sclerosis developed persisting orthosta tic headache following a diagnostic lumbar puncture (LP). The LP was prompt ed by an acute insensibility of the left side to pain and temperature from dermatome Th6. Six days after LP, cranial magnetic resonance imaging (MRI) revealed diffuse pachymeningeal thickening and gadolinium enhancement, whic h increased in magnitude over the next months. Based on the typical headach e and the diffuse pachymeningopathy, we made the diagnosis of chronic intra cranial hypotension caused by a persistent cerebrospinal fluid (CSF) leak f ollowing LP. Six months after LP, headache resolved in response to an epidu ral blood patch. Clinical improvement was paralleled by a decrease in pachy meningeal thickening and gadolinium enhancement after epidural blood patch. Orthostatic headache recurred two months later when the patient lifted a h eavy basket. Accordingly, repeated MRI demonstrated an increase in pachymen ingeal abnormalities. Eleven months after initial LP, CT myelography reveal ed a persistent lumbar leakage of CSF at L4/5 level. The present case repor t demonstrates that chronic symptomatic CSF leakage can persist for months after LP. Most patients with post-lumbar persistent intracranial hypotensio n due to CSF leakage show diffuse dural thickening and gadolinium enhanceme nt. The amount of diffuse pachymeningeal gadolinium enhancement appears to parallel the severity of headache. Thus, repeated MRI is useful to establis h the diagnosis and to monitor the course of post-lumbar intracranial hypot ension.