93/365 Science Lesson and Miracle Cure?

Finally a diagnosis! EG is experiencing postural headaches and an isolated sixth nerve palsy secondary to spontaneous intracranial hypotension. This rare occurrence was the subject of a European Journal of Neurology article on 13 Oct 2006.

What happened, in short:

1. The inappropriate lifting of something too heavy

2. This caused a spontaneous tear in the dura, the membrane that surrounds the brain and spinal cord

3. The leak allows some Cerebrospinal Fluid (CSF) to escape

4. This causes low pressure in the spinal system, indicated by postural headaches (the ones where there is near total relief while reclining, but the brain shifts and causes headaches while upright)

5. In an upright position the brainstem sags over the clivus causing pressure on the left 6th nerve, the one that allows for lateral movement of the left eye.

6. This eventually results in a palsy, where the eyes aren't tracking together, creating two separate images for the brain and horizontal diplopia (double vision).

THE TREATMENT

Plan A

In some cases, where the tear is minor, the body will self-repair. This calls for total, horizontal bed rest and a general increase in fluids, especially caffiene. The wonderful neuro-opthalmologist we saw recommended buckets of mountain dew, the drink with a great deal of bang for the buck in the caffiene department. Sadly, Mountain Dew tastes like loose, bubbly mucus, but self repair is a lot easier than plan B.

Plan B

1. He will undergo a radio isotope cisternogram. This test uses a small amount of radioactive material, inserts it into the lumbar space of the spine, and then a scan is performed to locate the position of the tear. Hopefully the tear will be found, but in some cases it is too small to locate.

2. Next up is the epidural blood patch, performed at least 24 hours after the cisternogram. In this procedure a small amount of his own blood is injected into the lumbar space. His blood will, presumably, plug the leak providing immediate relief of headaches, and within a few days, with the return of normal CSF fluids eliminates the sag of the brainstem on the left sixth nerve, the palsy is corrected, and the double vision ends. If they cannot locate the tear during the cisternogram, multiple blood patch procedures can be performed.

3. There is an outside chance that the blood patches are unsuccessful (and we have no reason to believe they won't work). Then it is possible to create a fibrin glue and patch. This is a patch made of the patient's blood and other agents.

4. On the extreme outside chance that all patches fail there is an option of surgical repair. But we don't want to go there.