Abstract
Dear sir We thank Dr Ferrante for his comments. We agree that gadolinium brain MRI is important to detect spontaneous intracranial hypotension syndrome (SIH), especially in patients with atypical presentations (1, 2) such as nonpostural headache, orthostatic headache with normal CSF pressure, and headaches closely resembling primary exertional headaches and chronic daily headaches.
In our study (3), gadolinium was administered to all our study patients except one (Case 15). None of the MRI studies showed diffuse pachymeningeal enhancement, a finding which would be typical for SIH if present. Fifteen of our 18 patients were responsive to indomethacin. Two of the remaining three patients who didn’t respond to indomethacin improved after spinal taps (Cases 10 and 17). The only patient (Case 4) who did not respond to indomethacin or spinal tap had normal gadolinium-enhanced MRI. The patient (Case 15) who refused gadolinium injection responded to indomethacin as well. Base on the clinical features, treatment response and MRI findings, the likelihood of SIH in our study cases was very low.