Citations

Dr Brazis has written a review of the literature on the clinical manifestations of idiopathic intracranial hypertension, possible associated venous hypertension and intracranial dural venous sinus abnormalities, and a brief discussion of medical and surgical therapies. The preferred terminology for this condition is idiopathic intracranial hypertension, but pseudotumour cerebri is so engrained in the literature that it stubbornly remains (1). The manuscript covers the literature well, and the information reviewed serves as an excellent reference source for interested readers. Unfortunately, Dr Brazis has noted the conflicting expert opinions regarding success, failure and complications for each of the surgical procedures, and, as a result, his summary discussion is barren of any algorithm of management, or even recommendations in approaching these difficult patients.

Vascular compression is a well-established cause of cranial nerve neuralgic syndromes. A unique case is presented that demonstrates that vascular compression may be a possible cause of occipital neuralgia. A 48-year-old woman with refractory left occipital neuralgia revealed on magnetic resonance imaging and computed tomographic imaging of the upper cervical spine an atypically low loop of the left posterior inferior cerebellar artery (PICA), clearly indenting the dorsal upper cervical roots. During surgery, the PICA loop was interdigitated with the C1 and C2 dorsal roots. Microvascular decompression alone has never been described for occipital neuralgia, despite the strong clinical correlation in this case. Therefore, both sectioning the dorsal roots of C2 and microvascular decompression of the PICA loop were performed. Postoperatively, the patient experienced complete cure of her neuralgia. Vascular compression as a cause of refractory occipital neuralgia should be considered when assessing surgical options.

Two patients with cerebrospinal fluid (CSF) leak, one at the level of fourth thoracic spine and another with undetermined level of leak, presented with paradoxical postural headaches in that the headaches were present when in a horizontal position and resolved if the patients were upright. One patient improved spontaneously and the other responded to a targeted epidural blood patch. Paradoxical postural headache is yet another headache type that can be associated with CSF leak and CSF volume depletion. Its mechanism is uncertain, but it could be related to congestion and dilatation of cerebral venous sinuses and large veins.