Abstract
A 54-year-old woman presented with a 12-month history of orthostatic headaches. Brain magnetic resonance imaging showed a large, left frontal mass with marked mass effect and transtentorial herniation (Figure 1). Surgical resection confirmed a meningioma and led to headache resolution. The orthostatic nature of this patient’s headache is likely explained by gravity worsening transtentorial herniation upon standing, leading to traction of intracranial pain-sensitive structures (1).
(a) Axial 2 image: 3.3 × 3.1 × 2.9 cm3 extra axial mass adjacent to the superior left frontal lobe with significant vasogenic edema. (b) Axial FLAIR: trapped anterior portion of right lateral ventricle and dilatation of the occipital horn of the right lateral ventricle presumably due to obstruction of foramen of Monro. (c) Sagittal T1 image showing significant transtentorial herniation compressing the midbrain.
There is a differential diagnosis of orthostatic headache that extends beyond a cerebrospinal fluid leak and this includes intracranial space occupying lesions. Cerebral imaging is therefore warranted before attempting a lumbar puncture in evaluating an orthostatic headache.
Our institutional review board does not consider a single case report to be human research, thus patient consent was not obtained.