Mustafa, Rafid

Background Spontaneous intracranial hypotension (SIH) results from cerebrospinal fluid (CSF) leakage due to spinal dural tears or CSF–venous fistulas. Orthostatic headache is the hallmark presentation, though severe downward displacement of the brainstem may lead to altered consciousness or coma. Definitive treatments include targeted epidural blood patches, venous embolization, or surgical repair. Methods This article reviews the role of the Trendelenburg position as a temporizing measure in the acute management of SIH. We describe the correct technique, physiologic rationale, and practical considerations for its application, with attention to both therapeutic and diagnostic utility. Discussion Positioning the patient with the feet elevated above the head can reduce brain sag and provide short-term symptomatic relief while awaiting definitive treatment. Although the Trendelenburg position is widely used in practice, supporting evidence remains limited, and clinicians must be aware of its benefits, indications, and inherent limitations. Its appropriate application may assist in stabilizing patients with acute or severe SIH, particularly those with impaired consciousness, until more definitive interventions are pursued.

Abstract Case Description: A 73-year-old female with history of stage IIIC high-grade mixed endometroid and serous ovarian cancer in remission presented with lower extremity weakness and paresthesias for several months ultimately wheelchair bound by presentation. Her exam was notable for severe proximal greater than distal lower extremity weakness, allodynia, absent patellar and Achilles reflexes, and diminished vibration and pinprick sensation. MRI demonstrated symmetric enhancement of the spinocerebellar tracts in the lateral cord from T6-T9. EMG showed a length-dependent axonal predominant sensorimotor neuropathy. The differential included metabolic, paraneoplastic, or inflammatory etiologies of her myelopathy. CSF studies revealed TNCs 30, elevated kappa free light chain, and negative cytology. Autoimmune/paraneoplastic myelopathy panels were negative. With her past history of cancer, FDG PET performed showed a right hypermetabolic chest wall and upper abdominal mass. Core needle biopsy demonstrated recurrence of high-grade carcinoma of mullerian origin consistent with recurrence of ovarian cancer. Her in-hospital treatment included 5 days of 1g IV methylprednisolone and seven sessions of PLEX. Her exam improved following PLEX with improvements in strength, sensation, and neurogenic bowel and bladder. She also started Carboplatin and Doxorubicin chemotherapy prior to discharge. She continued 60mg prednisone after discharge. She unfortunately had many hospitalizations for infections and anemia impacting her neurological recovery and strength has declined. Discussion: This case illustrates an interesting case of paraneoplastic myelopathy as the presenting symptom for relapsed ovarian cancer previously in remission for more than 10 years. The case shows the importance of keeping a paraneoplastic process on the differential when imaging findings and clinical syndrome are consistent with a paraneoplastic myelopathy even though the patient did not have a known, active cancer or positive antibodies identified. The work-up for malignancy is crucial as cancer-specific therapy is needed for hopeful symptom improvement.

This article highlights herpes zoster radiculitis, a condition that predominantly affects elderly patients and classically presents with progressive limb weakness, pain, and vesicular rash. Neuroimaging with MRI may demonstrate nerve root enlargement with T2-hyperintensity and gadolinium enhancement. Diagnosis can be confirmed with varicella zoster virus PCR in CSF. Effective treatment includes IV acyclovir and neuropathic pain agents such as gabapentin, which together can lead to symptomatic improvement. Early diagnosis and comprehensive treatment are crucial to prevent complications. Patients with zoster-associated plexopathy have a higher incidence of postherpetic neuralgia compared to those with herpes zoster rash alone. Thus, multimodal treatment involving antivirals, rehabilitation, and pain management is essential for recovery.