Post-Traumatic Head Injury with Suspected Intracranial Hypertension

Case at a Glance

A 30-year-old South Asian male presents with chronic neurological symptoms following head trauma, including positional headaches, pulsatile sensations, cognitive impairment, and visual disturbances. Imaging reveals cerebral atrophy and optic nerve enhancement.

Patient's Story

The patient, a 30-year-old male (height 5'10", weight 220 lbs), sustained a head injury several months prior and has since experienced persistent symptoms. He reports pressure sensation at the vertex of his head that worsens with postural changes, along with pulsatile sensations synchronized with his heartbeat affecting his face, neck, and upper abdomen. Additional symptoms include brain fog, difficulty with visual focus, lightheadedness, and chest tightness. He has a history of severe obstructive sleep apnea and notes symptom exacerbation after lying supine or using CPAP therapy. His current medication regimen includes rosuvastatin for dyslipidemia.

Initial Assessment

Physical examination and initial workup revealed concerns for possible elevated intracranial pressure given the constellation of symptoms and their relationship to positioning. The patient's symptoms, particularly the positional nature of the headaches and pulsatile sensations, raised suspicion for intracranial hypertension or venous outflow obstruction.

The Diagnostic Journey

Initial brain MRI demonstrated mild cerebral atrophy with increased cerebrospinal fluid spaces. Follow-up MRI with gadolinium contrast revealed enhanced signal intensity involving the left optic nerve. CT aortogram was performed and showed normal results. Abnormal cardiac stress testing suggested possible ischemia on two separate occasions. The patient questioned whether magnetic resonance venography (MRV) would be appropriate to evaluate for cerebral venous sinus stenosis or other venous outflow abnormalities.

Final Diagnosis

Post-traumatic syndrome with suspected intracranial hypertension, pending definitive cerebrospinal fluid pressure measurement via lumbar puncture.

Treatment Plan

The consulting physician recommended lumbar puncture with opening pressure measurement as the definitive diagnostic test for suspected elevated intracranial pressure, rather than proceeding directly to MRV. This approach would provide direct measurement of cerebrospinal fluid pressure and guide further management decisions.

Outcome and Follow-up

Case pending lumbar puncture results to confirm or exclude intracranial hypertension. Further imaging studies including MRV may be considered based on cerebrospinal fluid pressure findings and clinical response to initial interventions.