J Clin Neurol.  2008 Jun;4(2):89-93. 10.3988/jcn.2008.4.2.89.

Pneumocephalus in Patients With Orthostatic Headache

• Yoon SJ
• Oh GS
• Lee SJ
• Lee BR
• Chun JU
• Yu IK

• KMID: 2178928
• DOI: http://doi.org/10.3988/jcn.2008.4.2.89

Abstract

Cerebrospinal fluid (CSF) leak or shunt overdrainage is a well-known cause of orthostatic headaches and low CSF pressures. We report two cases of orthostatic headache with pneumocephalus on brain imaging. The orthostatic headache developed after drainage of spinal operation site and epidural block. Brain MRI revealed characteristic findings of CSF hypovolemia including pachymeningeal enhancement and mild subdural fluid collections. Air was also observed in the ventricular or subarachnoid space in both patients, which might enter the subarachnoid or ventricular space during a procedure via the pressure gradient or an injection.

Keyword

Orthostatic headache; Pneumocephalus; CSF hypovolemia

MeSH Terms

Brain
Drainage
Headache
Humans
Hypovolemia
Neuroimaging
Pneumocephalus
Subarachnoid Space

Figure

• 

  Figure 1 Brain MRI of case 1. T2-weighted axial images (A, B, and C) show massive pneumocephalus involving both lateral ventricles, basal cisterns, sylvian cisterns, the left ambient cistern, retrocerebellar cisterns, cerebellar folia, the anterior interhemispheric fissure, and cortical sulci (subarachnoid space). Gradient echo images (D, E, and F) show markedly exaggerated findings relative to T2-weighted axial images. Sagittal image (G) reveals the air pathway, and enhanced MRI coronal images (H and I) demonstrate diffuse nonnodular, uninterrupted pachymeningeal gadolinium enhancement.

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  Figure 2 Brain images of case 2. Brain CT (A) was performed 1 day before brain MRI. Note the presence of exaggerated air in the right anterior frontal horn on the gradient echo image (B) relative to the brain CT and T2-weighted axial images (C). Slightly prominent extracerebral space at anterior frontal areas - which is suggestive of minimal subdural hygroma - is also observed on an enhanced T1-weighted sagittal MR image (D). Arrows indicate air in the right anterior frontal horn.

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