Case Report of Compensated Idiopathic Intracranial Hypertension due to Traumatic Cerebrospinal Fluid Fistula

Abstract

Introduction
Disorders of intracranial pressure, both Intracranial Hypertension (IH) and Cerebrospinal Fluid Hypotension (CSFH), are causes of headache and can impair quality of life and lead to various complications. These conditions can cause symptoms such as transient visual loss, tinnitus, gait and balance disturbances, but positional headache is the main symptom. In this report, we present the case of a patient who was diagnosed with Idiopathic Intracranial Hypertension (IIH) and later developed a change in the pain pattern, caused by traumatic Cerebrospinal Fluid Fistula.
Objective
To report the case of a patient diagnosed with Idiopathic Intracranial Hypertension (IIH), who had a good response to medical treatment for several years but experienced worsened headache and a change in pain pattern (becoming orthostatic) following a Traumatic Brain Injury (TBI).
Results
Female patient, 33 years old, obese, accompanied in an outpatient headache clinic in Joao Pessoa - PB. In 2018, she presented with a progressive holocranial headache that worsened with dorsal decubitus, accompanied by transient visual darkening. She was diagnosed with IIH after a cerebrospinal fluid (CSF) collection and exclusion of other causes. Since then, she has been taking Topiramate and making lifestyle changes, such as regular physical activity, dietary changes, and weight loss, resulting in significant improvement of symptoms for a few years. In January 2023, she suffered a mild TBI (hit her head on a cabinet) and a few days later, she started experiencing intense and almost daily headaches, but different from the previous ones. Now, the pain worsened or appeared in upright position and was accompanied by clear, colorless, odorless, fluid and constant rhinorrhea in the right nostril, ear fullness, nausea, and occasional vomiting. At that time, she stopped the medication and had partial improvement of symptoms.
After reporting these events during the follow-up appointment, she underwent investigation with Magnetic Resonance Imaging (MRI) with cerebrospinal fluid flow study, which revealed a frontoethmoidal meningoencephalocele through a bone defect in the cribriform plate. In a joint decision with the Neurosurgery team, it was opted not to correct the fistula and to proceed with a ventriculoperitoneal shunt. She had a great improvement after the procedure, was discharged days later without symptoms.
Conclusion
Therefore, we report a case of a patient with secondary headache due to IIH that achieved good symptom control for several years. However, after a MTI injury, the headache recurred with a new pattern and was accompanied by new symptoms. She was diagnosed with a Cerebrospinal Fluid Fistula and Meningoencephalocele, and underwent ventriculoperitoneal shunt placement. She showed good progress and response to treatment.