Cough is a complex physiologic response that protects tracheobronchial airway from unwanted secretions and foreign materials. In this report, we describe a patient with dural tear and CSF leak as a result of coughing.
A 19-year-old female with a history of cystic fibrosis came in the ER (Emergency Room) of our hospital complaining of severe bifrontal headache. She was having positional headache for the last three weeks. Her Review of Systems was unremarkable except for frequent bouts of coughing. Examination of central nervous system was unremarkable except for neck stiffness. Examination of eyes including intraoccular pressure and fundoscopy were unremarkable. CT scanning of her head did not reveal any abnormality. Examination of cerebrospinal fluid (CSF) including cultures was unremarkable. She was discharged but after two weeks came to ER with persisting headache. MRI (magnetic resonance imaging) of her brain showed a 4 mm subdural fluid collection overlying the right cerebral convexity. Considering the possibility of CSF leak, MRI of her thoracic spine was done that showed fluid collection posterior to thecal sac within the spinal cord with signal characteristic consistent with CSF fluid on T2 weighted imaging. Later on Computed Tomography (CT) myelogram (Fig. 1) confirmed CSF leak at the level of L1 and L2. A diagnosis of right L1 spontaneous CSF leak from dural tear was confirmed during surgery. After the repair of tear, her headache disappeared completely.
During the bouts of coughing intrathoracic pressures of up to 300 mm Hg (1) may be achieved and it has been shown to be associated with serious complications like pneumomediastinum (2) or pneumothorax, fracture of ribs, herniation of lung through intercostal space (3), tracheal wall rupture (4), and diaphragmatic rupture (5).Most spinal CSF leaks are iatrogenic, occurring after lumbar puncture or spinal surgery, or they may be due to dural laceration caused by a blunt trauma or penetrating spinal trauma. Spinal CSF leaks without any obvious preceding trauma, however, are increasingly recognized as a cause of postural headaches associated with intracranial hypotension (6). The exact cause of spontaneous CSF leak often remains unclear; however, the combination of a trivial precipitating event and an underlying weakness of the spinal meninges is generally suspected. A large majority of patients reports a previous trivial trauma such as coughing, lifting, pushing, sports activities, roller coaster ride (7), and the like. The disease is usually self-limiting, but in selected cases, surgical ligation of leaking dura has been found to be satisfactory (6).
Our patient had spontaneous CSF leak that we believe was secondary to bouts of violent coughing. One should suspect the possibility of spontaneous CSF leak in a patient with positional headache. MRI of spine and CT myelogram may help us in confirming the diagnosis. Most of the leaks resolve spontaneously but in few patients surgical repair of the dura may be necessary.
Ioana Amzuta, None.