Abstract
A 71-year-old female developed a right-sided, non-orthostatic headache, associated with right facial and neck pain. She later developed right-sided sensorineural hearing impairment (confirmed with audiometry), and a right-sided facial palsy. She then began to experience episodes of rotational vertigo, which prompted her presentation to neurology.
Magnetic resonance imaging (MRI) demonstrated bilateral subdural hygromas and diffuse pachymeningeal thickening with enhancement, as well as pathological enhancement of the right facial nerve. Extensive laboratory testing did not identify an infective or inflammatory aetiology, and malignancy screening was negative. A lumbar puncture was performed with an opening pressure of 5cmH20. Spinal MRI and nuclear medicine myelography did not identify a CSF leak.
Six weeks after an empirical blood patch, the patient reported substantial improvement in her symptoms. Repeat MRI demonstrated improvement in the pachymeningeal enhancement and resolution of the hygromas.
This is a case of spontaneous intracranial hypotension (SIH) presenting with non-orthostatic headache, facial nerve palsy and vestibulocochlear dysfunction. Delayed diagnosis and misdiagnosis are common in SIH. Often the orthostatic characteristics of the headache become less apparent with a longer duration of symptoms. Cranial nerve palsies have been reported, however mostly involving the oculomotor, trochlear or abducens nerves. Vestibulocochlear manifestations can also result from associated changes in perilymph pressure. It is exceptionally rare for SIH to affect the facial nerve, and to our knowledge, this is the first reported case of SIH to involve the facial nerve clinically and radiologically.
