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A 16-year-old boy with a headache, back neck pain and positional vertigo

A 16-year-old boy was admitted for a few days’ history of mild headache, moderate to severe posterior neck and dorsal back pain, nausea, vomiting many times during the day, and subjective positional vertigo. There was no night awakening for pain, neither night or on awakening vomit. He had been treated with ibuprofen without benefit. His history was unremarkable.

On admission, physical and neurological examinations were unremarkable except for thoracolumbar pain during the flexion-extension of the trunk and refusal to stay in the orthostatic (the upright posture) position. Systemic blood pressure was 100/65 mm Hg. An ear, nose and throat (ENT) examination was negative.

A brain and spine MRI showed cerebral dural sinus congestion, with a widespread meningeal enhancement after administration of contrast (figure 1A,B).



Figure 1 
(A) Sagittal postcontrast T1-weighted section. The arrow indicates the expansion of dural venous sinuses. (B) Coronal postcontrast T1-weighted image. The arrow shows the venous distension with pachymeningeal enhancement.



Which is the most likely diagnosis?

1. MRI evidence associated with cerebral spinal fluid (CSF) hypotension.

2. Pseudotumour cerebri. …