Spontaneous Intracranial Hypotension, Menière’s Disease and Secondary Benign Paroxysmal Positional Vertigo: Case Report

Background/Objectives: Spontaneous intracranial hypotension (SIH) is a rare pathology that arises in the context of a known or suspected cerebral spinal fluid (CSF) leak. A key symptom of SIH is an orthostatic headache; however, additional neurological complications are common. This case study not only highlights the co-existence of Menière’s disease and SIH but describes a subsequent complication of benign paroxysmal positional vertigo (BPPV) and management thereof. Case Description: The patient is a 61-year-old female who presented to the emergency department due to an intractable headache, right sided weakness and aphasia. CT/MRI revealed a subdural hematoma overlying the left cerebral hemisphere measuring up to 8 mm with 4 mm left to right midline shift. Fluoro-guided total spine myelogram, cisternogram, and lumbar epidural blood patch were performed for suspected SIH. As headache, right sided weakness and aphasia resolved, the patient began reporting onset of constant “spinning” dizziness, tinnitus and aural fullness mimicking symptoms of a Menière’s attack. The vestibular examination was consistent with compensated bilateral Menière’s disease (left > right) and right horizontal canalithiasis BPPV. The patient was treated with Gufoni and Lempert maneuvers with complete resolution of positional dizziness and associated nystagmus along with improved balance and gait. Discussion/Conclusions: This case study highlights the importance of multidisciplinary assessment in complex neurological cases and specifically recommends that patients with Menière’s disease accompanied by intractable headaches undergo extended neuroradiological examination of the brain to exclude underlying spontaneous intracranial hypotension syndrome.