0A 38-year-old Asian male presented with "sudden onset of worst headache of my life" that was generalized in nature and not associated with nausea, vomiting, or seizures. His past history was unremarkable. He was initially treated for sinusitis and prescribed a course of antibiotics and nasal decongestants, which initially improved his symptoms. After approximately one month, the patient's headache reoccurred and persisted. He was evaluated in the emergency room for recurrent head ache and urgent computed tomography (CT) brain revealed bilateral subdural collections (images not shown). With the diagnosis of bilateral subdural hematoma, he was considered for possible surgical intervention. Later careful history analysis revealed that his headache was worst when standing or sitting, but relieved when lying down. Other causes of headache were ruled out. On examination, all vital signs were within normal limits. There was no neck stiffness and no rash. Systemic examination was unremarkable. On neurological evaluation, patient was alert, oriented with intact higher cognitive function including speech. Cranial nerves including fundus exam, motor, sensory, and cerebellar examination demonstrated nonfocal neurological exam and no abnormality detected. Considering the patient's age, symptoms, unremarkable past medical problems, nonfocal exam, and radiological findings prompted us to consider SIH as the diagnosis and magnetic resonance imaging (MRI) brain was ordered to confirm it. MRI brain revealed [Figures 1 and 2] the classic features of IH including subdural hematoma collection, descent of cerebellar tonsils, effacement of the prepontine cistern and interpeduncular cistern, inferior displacement of the optic chiasm, reduced mammillary body and pontine distance due to the descent of the mammillary body, crowding of posterior fossa due to brainstem descent, descent of cerebellar tonsils, sagging of tuber cinereum, inferior displacement of splenium, and descent of the fastigium of the fourth ventricle.
MRI myelography showed epidural fluid at the C2-C4 level with possible dural tear at C2 on right side and C3, C4 on the right side. Epidural fluid was also seen in the entire dorsal region and in the upper lumbar region without any obvious dural tear. The patient was scheduled for an epidural patch, which was performed at the cervical level using 12 cc of autologous blood. Symptoms resolved significantly after the epidural blood patch. Repeat CT head 3 months postblood patch showed resolution of the subdural fluid collection [Figure 3]. Patient is asymptomatic till date.