Spontaneous Intracranial Hypotension and Dural Tear in a Pediatric Patient After a Minor Fall: A Case Report

Spontaneous intracranial hypotension (SIH) is a rare cause of positional headache and vomiting. SIH is often caused by extravasation of cerebrospinal fluid (CSF) from a dural tear with orthostatic headache, dizziness, nausea, vomiting, and potentially, cranial nerve deficits. Diagnosis of SIH requires clinical suspicion; imaging; potentially, lumbar puncture; and computed tomography (CT) myelography. Management of SIH can require neurosurgical intervention. SIH is rare in the adult population, with fewer reported pediatric cases. Here we present a pediatric case of SIH after a minor fall.

A 14-year-old boy presented to the Emergency Department (ED) with a complaint of orthostatic headache, nausea, and vomiting for 3 days after falling off a barstool and landing on his bottom. Laboratory evaluation, electrocardiogram, and CT scan of the head were unremarkable. The patient was admitted with consultation to Neurosurgery. While an inpatient, the patient received magnetic resonance imaging (MRI) of the head and spine, which showed CSF extravasation concerning for SIH with a ruptured sacral arachnoid cyst. Symptoms improved with supportive care, i.v. fluids, and bed rest. He was discharged home without symptomatic recurrence at neurosurgical follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SIH should be included in the differential diagnosis for a patient who experiences minor trauma with orthostatic headache, nausea, and vomiting. Diagnostic evaluation includes intracranial imaging, with MRI as the imaging modality of choice. Treatment of SIH starts with a trial of supportive management such as bed rest, i.v. and oral fluids, and caffeine. If this fails, patients may require interventional management including epidural blood patch, fibrin glue, or surgical closure.