Bu Hayee

Irini Yanny

James Davis

Nick Moran

Patrick Dubois

Sukhdev Chatu

Springer - Publisher Connector

JOURNAL OF MEDICAL
CASE REPORTS
Davis et al. Journal of Medical Case Reports 2014, 8:456
http://www.jmedicalcasereports.com/content/8/1/456CASE REPORT Open AccessSpontaneous cerebrospinal fluid leak following a
pilates class: a case report
James Davis1*, Irini Yanny1, Sukhdev Chatu1, Patrick Dubois1, Bu Hayee1 and Nick Moran2Abstract
Introduction: A spinal cerebrospinal fluid leak is the most common cause of spontaneous intracranial hypotension
which is an uncommon but increasingly recognized cause of headache. This article describes the first reported case of
pilates being associated with a spontaneous spinal cerebrospinal fluid leak whilst also highlighting the key information
about spontaneous cerebrospinal fluid leaks that will be useful to the general clinician.
Case presentation: We present the case of a 42-year-old Caucasian woman who developed a low-pressure
headache following a pilates class. A computed tomography scan of her head demonstrated bilateral chronic
subdural hematomas and cerebellar descent. Magnetic resonance imaging of her spine revealed the presence of
extensive extradural cerebrospinal fluid collections. She responded to conservative management and repeat
neuroimaging after symptom resolution revealed no abnormalities.
Conclusions: Awareness and early recognition of spontaneous intracranial hypotension is important to prevent
unnecessary investigations and delay in treatment. Pilates may be a risk factor for the development of a
spontaneous cerebrospinal fluid leak.
Keywords: Cerebrospinal fluid leak, Pilates, Subdural hematoma, Low pressure headache, Epidural blood patch,
Connective tissue disorderIntroduction
Spontaneous intracranial hypotension (SIH) is an un-
common but increasingly recognized cause of headache
with an incidence of approximately one out of 50,000
[1]. The most common cause is a spontaneous spinal
leak [1]. This article describes a case of SIH secondary
to a spontaneous spinal cerebrospinal fluid (CSF) leak in
a patient who attended ‘pilates reformer’ classes. Given
the rarity of this condition, this article will also provide
key information about SIH and spontaneous CSF leaks
that will be useful to the general clinician.
Case presentation
A 42-year-old Caucasian woman was admitted to our in-
stitution with a four-week history of gradually worsening
headache after she had attended a ‘pilates reformer’ class.
She described the sudden feeling of a ‘pop’ in the left side
of her neck during a certain pilates reformer maneuver* Correspondence: jamesdavis1@nhs.net
1Department of Gastroenterology, Kings College Hospital, Denmark Hill,
London SE5 9RS, UK
Full list of author information is available at the end of the article
© 2014 Davis et al.; licensee BioMed Central. T
Commons Attribution License (http://creativec
reproduction in any medium, provided the or
Dedication waiver (http://creativecommons.or
unless otherwise stated.but there was no head injury. Our patient developed a
headache after one hour, which improved when lying flat.
She initially presented to primary care where she received
treatment (opiate analgesic and muscle relaxant) for sus-
pected trapezius muscle injury and referred head pain.
Over a four-week period, our patient underwent a series
of physiotherapy sessions with intensive neck manipula-
tion. During this time, our patient had a number of inter-
actions with primary care, in addition to one emergency
department attendance after two-and-a-half weeks. There
was no relief with simple or opiate analgesics. The severity
of the headache had a profound impact on her ability to
perform her activities of daily living. There was no prior
history of migraine, head or spine trauma, recent travel or
the use of any anticoagulants. She had a history of medic-
ally refractory ulcerative colitis treated with subtotal colec-
tomy and subsequent ileo-anal pouch anastomosis. Our
patient reported some relief of symptoms in response to a
nonsteroidal anti-inflammatory drug (NSAID) but experi-
enced an episode of pouchitis and NSAID treatment was
terminated.his is an Open Access article distributed under the terms of the Creative
ommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
iginal work is properly credited. The Creative Commons Public Domain
g/publicdomain/zero/1.0/) applies to the data made available in this article,
Figure 1 Non-contrast computed tomography head (axial and saggital sections) showing bilateral chronic subdural hematomas (red
arrows), with cerebellar descent (blue arrow) but with no evidence of midline shift.
Davis et al. Journal of Medical Case Reports 2014, 8:456 Page 2 of 4
http://www.jmedicalcasereports.com/content/8/1/456On admission to our institution she was afebrile with
normal blood pressure and pulse. There were no menin-
gitic signs. An examination of the cranial nerves, periph-
eral nervous system and spine was unremarkable. Basic
hematological and biochemical blood tests were unre-
markable. A computed tomography (CT) scan of her
head demonstrated bilateral chronic subdural hemato-
mas and cerebellar descent (Figure 1). Magnetic reson-
ance imaging (MRI) of her spine revealed the presence
of extensive extradural CSF collections (Figure 2) but
was unable to identify the exact location of the dural
tear. Initially, we opted for conservative management
with bed rest and caffeinated drinks rather than use anFigure 2 T2-weighted magnetic resonance imaging (saggital section)
L2-S2 (red arrow) and posterior to the spinal cord at the level of T1-9
compression and the spinal cord has normal signal.epidural blood patch. Our patient responded well to the
conservative management with a significant improve-
ment in her headaches. She was discharged two weeks
after admission and one month after discharge repeat
neuroimaging revealed normal intracranial appearances
(Figure 3). Our patient was reviewed following this re-
peat neuroimaging: she remained asymptomatic and,
therefore, no further routine follow-up was arranged.
Discussion
The hallmark symptom of intracranial hypotension is an
orthostatic headache that is worse when in the upright
position and resolves or improves when lying flat. Othershowing cerebrospinal fluid collections anterior to the theca at
and also at C1-2 (blue arrows). There is no evidence of spinal cord
Figure 3 Intracranial magnetic resonance imaging (axial: T2-weighted and saggital: T1-weighted sections) performed at one month
after discharge shows normal intracranial appearances. The bilateral extra-axial collections and cerebellar descent have resolved.
Davis et al. Journal of Medical Case Reports 2014, 8:456 Page 3 of 4
http://www.jmedicalcasereports.com/content/8/1/456symptoms include diplopia, hearing loss, vertigo and
meningism [1].
The most characteristic findings on MRI of the head is
pachymeningeal enhancement with downward displace-
ment of the brain, which can be mistaken for a Chiari
type I malformation [1]. Subdural hematomas are com-
mon in patients with SIH and are usually bilateral but
without mass effect [1]. Since the most common cause
of SIH is a spontaneous spinal CSF leak, patients should
undergo spinal imaging to try and identify a dural tear.
CT or MRI myelography are the preferred spinal im-
aging technique as they provide accurate localization of
the tear compared to MRI [1]. Localization of the tear is
useful when considering the use of an epidural blood
patch; the treatment of choice in patients who have
failed conservative management (bed rest, NSAIDs and
caffeinated drinks) [1]. Since our patient responded to
conservative measures, she did not require an epidural
blood patch. There was, therefore, no requirement to de-
termine the exact location of the dural tear using myelo-
graphy. Clinical improvement usually precedes resolution
of the abnormalities documented on neuroimaging of the
head although the time between symptomatic and MRI
resolution is variable [1].
The underlying cause of spontaneous CSF leaks re-
mains unknown but there is an association with con-
nective tissue disorders [1]. Up to 20% of patients have
subtle sketetal abnormalities such as those seen in
Marfan syndrome (tall stature, joint hypermobility and
arachnodactyly) with no other stigmata of the disease. In
some of these patients there is abnormal expression of
fibrillin metabolism [1]. It has also been reported that in
patients with an underlying dural weakness a small trau-
matic event may be enough to produce a spontaneous
CSF leak [1]. In our patient, there was no evidence of a
connective tissue disease and we feel that a trivialtraumatic event during her pilates class resulted in the
development of a dural tear. A retrospective study of 30
patients with CSF hypovolemia describes one case of
spontaneous intracranial hypotension following a yoga
class [2]. However, there has been no previous docu-
mentation in the literature of ‘pilates reformer’ classes
being associated with a spontaneous spinal CSF leak
and, to our knowledge, this is the first case.
Conclusions
The most common cause of SIH is a spontaneous spinal
CSF leak and MRI findings in these patients include
pachymeningeal enhancement, downward displacement of
the brain and subdural hematomas. This case highlights
the need for increased awareness and early recognition of
SIH in order to prevent unnecessary investigations and
delay in treatment. Most importantly, this case raises the
possibility of pilates being a risk factor for the develop-
ment of a spontaneous CSF leak.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for re-
view by the Editor-in-Chief of this journal.
Abbreviations
CSF: cerebrospinal fluid; CT: computed tomography; MRI: magnetic
resonance imaging; NSAID: nonsteroidal anti-inflammatory drug;
SIH: spontaneous intracranial hypotension.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All six authors were involved in the clinical care of this patient and in
addition all authors helped to draft the manuscript. All authors read and
approved the final manuscript.
Davis et al. Journal of Medical Case Reports 2014, 8:456 Page 4 of 4
http://www.jmedicalcasereports.com/content/8/1/456Author details
1Department of Gastroenterology, Kings College Hospital, Denmark Hill,
London SE5 9RS, UK. 2Department of Neurology, Kings College Hospital,
Denmark Hill, London SE5 9RS, UK.
Received: 11 August 2014 Accepted: 10 November 2014
Published: 21 December 2014
References
1. Schievink WI: Spontaneous spinal cerebrospinal fluid leaks and
intracranial hypotension. JAMA 2006, 295(19):2286–2296.
2. Chung SJ, Kim JS, Lee MC: Syndrome of cerebral spinal fluid hypovolemia:
clinical and imaging features and outcome. Neurology 2000,
55(9):1321–1327.
doi:10.1186/1752-1947-8-456
Cite this article as: Davis et al.: Spontaneous cerebrospinal fluid leak
following a pilates class: a case report. Journal of Medical Case Reports
2014 8:456.Submit your next manuscript to BioMed Central
and take full advantage of: 
• Convenient online submission
• Thorough peer review
• No space constraints or color ﬁgure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at 
www.biomedcentral.com/submit


Spontaneous cerebrospinal fluid leak following a pilates class: a case report

file:///data/remote/core/dit/data/Springer-OA/pdf/cb4/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjExODYvMTc1Mi0xOTQ3LTgtNDU2LnBkZg==.pdf

Spontaneous cerebrospinal fluid leak following a pilates class: a case report

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Springer - Publisher Connector