Case

A 38-year-old man underwent a lumbar puncture, having had 5 days of fever, headache and meningism. The procedure was performed in a single attempt with the patient seated, using a 22-G pencil-tip spinal needle. Six hours later, he had severe holocephalic headache, worse when upright and persisting despite analgesics. This was followed by an intense neck and lower back pain. His cerebrospinal fluid (CSF) opening pressure was 150 mmH₂O (normal 100–250), with polymorphonuclear cells 18/mm³ (0), lymphocytes 2/mm³ (< 5), protein 0.95 g/L (0.15–0.45), glucose 4.3 mmol/L (2.7–4.4), and negative Gram stain and culture. His plasma glucose level was 6.9 mmol/L (6.1–7.8). We gave intravenous antibiotics for a possible CNS infection, but despite completing 14 days of treatment, his excruciatingly severe headache and backache persisted, though he remained afebrile. Neurological examination was normal.

MR scan of the brain with contrast on the 20th day of illness showed a small subdural haemorrhage, diffuse pachymeningeal enhancement, engorged dural venous sinuses and a hyperaemic pituitary, all suggesting intracranial hypotension (figure 1). A …