Intended for healthcare professionals

Endgames Picture Quiz

Postural headache

BMJ 2009; 338 doi: (Published 19 March 2009) Cite this as: BMJ 2009;338:b911
  1. Omer Ali, foundation year 2, general medicine1,
  2. Maithili Srikantha, foundation year 2, general medicine1,
  3. Waseem Bhat, fixed term specialty appointment 2, trauma and orthopaedics2,
  4. Chika Edward Uzoigwe, fixed term specialty appointment 2, trauma and orthopaedics1
  1. 1Milton Keynes General Hospital, Milton Keynes MK6 5LD
  2. 2Hull Royal Infirmary, Hull HU3 2JZ
  1. Correspondence to: O Ali omerali{at}

    A 50 year old man, with known Marfan’s syndrome, was admitted with a one week history of severe headaches over the top of his skull, neck pain, and daily vomiting. His symptoms were greatly aggravated by standing, but they disappeared when he lay flat. He was systemically well and had no history of trauma. He had undergone an aortic root and metallic valve replacement 13 months previously and was on lifelong warfarin.

    On examination he had morphological features consistent with Marfan’s syndrome, including tall stature, pectus carinatum, arachnodactyly, joint hypermobility, and high arch palate. He did not have a fever. He had no neurological deficit, photophobia, or signs of meningism. His blood investigations were unremarkable except for an international normalised ratio of 3.8. Magnetic resonance imaging of the brain and lumbosacral spine was performed (figs 1-3 ).

    Fig 1 T2 weighted magnetic resonance imaging of the brain: axial view

    Fig 2 T2 weighted magnetic resonance imaging of the brain: sagittal view

    Fig 3 T2 weighted magnetic resonance imaging of the lumbosacral spine: sagittal view


    • 1 What do the magnetic resonance imaging scans show?

    • 2 What is the diagnosis?

    • 3 How would you treat this condition?


    Short answers

    • 1 The axial view of the brain (fig 4) shows bilateral subdural haematomas and venous engorgement of the superior sagittal sinus. The sagittal view (fig 5) shows caudal descent of the brainstem with protrusion of the cerebellar tonsils. The ventricles are reduced in size because of a decrease in cerebrospinal fluid (CSF). The net effect is that the brain seems to sag. In addition, the pons is flattened. A sagittal view of the lumbrosacral spine (fig 6) shows a capacious vertebral canal consistent with dural ectasia and a large meningocele at the second sacral vertebra.

    Fig 4 T2 weighted …

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