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Intracranial hypotension following multiple lumbar punctures

Case contributed by Frank Gaillard
Diagnosis certain

Presentation

Known metastatic choriocarcinoma.

Patient Data

Age: 35 years
Gender: Female

A small, faintly enhancing, hemorrhagic lesion with surrounding edema is seen involving the central sulcus of the right hemisphere. 

The patient went on to have surgery.

Histology

Paraffin sections show collections of markedly atypical cells within edematous and hemorrhagic brain parenchyma. These have irregularly shaped enlarged hyperchromatic nuclei, some with multiple nuclei and a variable amount of pale and vacuolated cytoplasm.

The tumor cells are AE1/3, CAM5.2, CK7, CK19 and EMA positive. They are BHCG, c-kit, PLAP, AFP, tyrosinase, GFAP, nestin and TTF-1 negative.

Final diagnosis

Metastatic choriocarcinoma.

MRI post intrathecal chemoRx

mri

Patient was receiving intrathecal methotrexate and developed postural headache (worse on standing).

MRI demonstrates typical appearances of intracranial hypotension with diffuse dural enhancement, subdural effusions, small ventricles, plump pituitary gland and engorged intracranial veins and rounded dural venous sinuses

The brainstem is slumped with reduced mamillopontine distance.

Case Discussion

This case demonstrates typical appearances of intracranial hypotension, in this case due to repeated lumbar punctures. The patient was treated with an epidural blood patch and symptoms resolved. 

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