Endgames Picture Quiz

Intractable headache after lumbar puncture

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4529 (Published 08 August 2011) Cite this as: BMJ 2011;343:d4529
  1. V St Noble, specialist registrar, radiology1,
  2. I Davagnanam, consultant neuroradiologist 2,
  3. S Farmer, consultant neurologist3
  1. 1Department of Radiology, Chelsea and Westminster Hospital, London, UK
  2. 2Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
  3. 3Department of Neurology, National Hospital for Neurology and Neurosurgery
  1. Correspondence to: I Davagnanam indran_davagnanam{at}yahoo.co.uk

A 17 year old man presented to the accident and emergency department with a severe headache, neck stiffness, fever, and photophobia. His blood tests showed neutrophylic leucocytosis and raised C reactive protein. A computed tomography scan of his brain was normal. Lumbar puncture detected 71 white blood cells (55% lymphocytes and 45% polymorphs) and was positive for enterovirus. A low cerebrospinal fluid (CSF) opening pressure was noted. His blood cultures also grew Streptococcus viridans. He was treated for viral meningitis and bacteraemia with intravenous aciclovir and antibiotics for two weeks, at which time he discharged himself. He presented again three weeks later with an intractable headache, which was reportedly aggravated by sitting up and standing; he also had back pain. His inflammatory markers at this time were normal. Magnetic resonance imaging of the brain and spine was performed (figs 1 and 2).

Fig 1 Coronal post-contrast T1 weighted magnetic resonance imaging of the brain

Fig 2 Midline sagittal (a) T2 weighted and (b) T1 weighted magnetic resonance imaging of the cervical spine. (c) Post-contrast parasagittal T1 weighted magnetic resonance imaging of the cervical spine

Questions

  • 1 What are the radiological findings?

  • 2 On the basis of magnetic resonance imaging and history, what is the likely diagnosis for the second admission?

  • 3 What further imaging may be helpful?

  • 4 How should this condition be managed?

Answers

1 What are the radiological findings?

Short answer

Crowding and caudal displacement (“sagging”) of the posterior fossa structures of the brain (fig 3A and B). Diffuse pachymeningeal enhancement (fig 4), engorgement of the epidural venous plexuses (fig 3C). Thoracic epidural collection (fig 3A and C).

Fig 3 Midline sagittal (a) T2 weighted and (b) T1 weighted magnetic resonance imaging of the cervical spine showing crowding of structures in the foramen magnum (arrows). (c) Post-contrast parasagittal T1 weighted magnetic resonance …

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