Difficult Diagnosis of Spontaneous Intracranial Hypotension with Nausea and Lower Abdominal Pain as Main Complaints: A Case Report

TL;DR

A 24-year-old woman was misdiagnosed with gynecological issues until she was correctly diagnosed with spontaneous intracranial hypotension, a rare condition causing headaches and abdominal pain.

Contribution

This case report highlights the rare presentation of spontaneous intracranial hypotension with non-typical symptoms such as nausea and lower abdominal pain.

Findings

The patient's symptoms were initially misattributed to gynecological issues but were later diagnosed as spontaneous intracranial hypotension.

Epidural saline infusion and blood patch therapy effectively alleviated the patient's headache and abdominal pain.

Imaging and diagnostic tests confirmed CSF depletion without spinal leakage, supporting the SIH diagnosis.

Abstract

Background and Clinical Significance: Symptoms of spontaneous intracranial hypotension include orthostatic headaches due to decreased cerebrospinal fluid (CSF) levels. Here, we present a 24-year-old female admitted to an obstetrics and gynecology department with primary complaints of lower abdominal pain and dysmenorrhea with subsequent diagnosis of spontaneous intracranial hypotension (SIH). Case Presentation: The patient had experienced nausea and lower abdominal pain independent of her menstrual cycle 5 days before admission, for which she visited the emergency department 3 days later. On admission, her symptoms were temporarily relieved by administering analgesics; thus, she was discharged. However, later, the symptoms worsened. Consequently, she returned to the emergency department for further evaluation, including blood tests, imaging, and endoscopy, which revealed no nausea- or abdominal pain-related organic abnormalities. On day 10, she developed a headache, aggravated by lying in the supine position and improved by sitting. Additional history revealed a diagnosis of SIH owing to the worsening abdominal pain in the supine position. An 111In CSF cavity scintigram showed no spinal fluid leakage; early intrabladder radioisotope (RI) accumulation was observed, and the residual 24 h CSF cavity RI was >30%. At a referral specialist hospital, an epidural saline infusion test was performed, which improved her headache and lower abdominal pain. Blood patch therapy improved her lower abdominal pain, headache, and dysmenorrhea. Conclusions: The final diagnosis was SIH, with symptoms attributed to CSF depletion. The patient also experienced rare paradoxical postural-related headaches and lower abdominal pain, aggravated by lying in the supine position, contributing to the final diagnosis.

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