Case Number 2

Date:
20/07/2026
Category
Headache & Pain Disorders
Case Title
A 33-year-old man with holocephalic headache and horizontal binocular diplopia
History of Present Illness
A 33-year-old male with a history of migraine presented to the emergency department (ED) with a 3-day history of headache. He preferred to rest in bed to relieve the headache. He was initially managed for a presumed migraine and discharged, but returned with persistent headache and the new onset of binocular horizontal diplopia.
Past Medical History
migraine, obesity, hypertension, chronic kidney disease (CKD)
Medications
No home medication
Allergies
None
Family History
No neurological history
Social History
Social history was significant for an office occupation and recreational axe throwing; he was a non-smoker, non-drinker, and denied recreational drug use.
Review of Systems
Review of systems was otherwise unremarkable.
Examinations
Neurological examination was significant for right eye abduction deficit, with horizontal diplopia noted to be worse at a distance. Optic discs were normal. The rest of neurological exam was normal.
Investigation
He had a brain MRI with GAD which is shown below
Investigation Images
Diffuse pachymeningeal enhancement; no leptomeningeal or parenchymal enhancement. There is extra-axial Fluid collection overlying both frontal lobes.
Sagittal T1 FLAIR suggested descent of mammillary bodies and posterior fossa crowding.
MR Venogram (MRV): Distention of venous sinuses, particularly on the right; no thrombosis identified.
Laboratory Tests
CSF Analysis: (LP done after MRI) Opening Pressure: 5 cm  (low). TNC: 13 (elevated; 81% lymphocytes, 19% macrophages). Protein: 18 g/l Microbiology/Cytology: Culture, gram stain, and cytology were negative for infection or malignancy. Flow Cytometry: Predominantly T-cells, CD4/CD8 ratio 7:1. Systemic Workup: Infectious/Inflammatory: ANA, vasculitis panel, CRP, Hep B/C, VDRL, Lyme, Biofire panel, and ACE levels were negative. Metabolic: TSH, B12, CBC, LFTs, folate, and ferritin were normal Body Imaging: Normal CXR, normal MRI spine, normal CT C/A/P, and PET scan showed no abnormal uptake.
Diagnosis
Spontaneous Intracranial Hypotension (SIH) Differential diagnosis: Pachymeningitis (IgG4-related, Sarcoidosis, GPA, Infectious) Cerebral Venous Sinus Thrombosis (ruled out by MRV) Carcinomatous Meningitis (ruled out by cytology/PET) Pseudotumor Cerebri (ruled out by low opening pressure) Intracranial hypotension
Discussion
Authors
Setareh Lahsaee, MD, FRCPC
Editor
References
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