Spring 2005

Medical Mystery

A resident of New Mexico, Michael Naranjo was blinded by an exploding hand grenade in Vietnam. Upon returning to the United States, he embarked on a career as a sculptor. Because of his blindness, Naranjo takes a unique tactile approach to creating and appreciating sculpture and has been allowed special access to touch museum sculptures around the world.

One day some 10 years ago, Naranjo was exercising at home and was afflicted by postural headaches, neck pain and nausea. "I took two aspirin and lay down and after about 20 minutes I felt better," Naranjo says. "But when I sat up I felt this all-consuming, massive pain in my head. All I could do was grab my head and lie back down and the pain subsided again in about 10 minutes."

He lay on the car seat while his wife drove him to the local hospital, where he underwent an evaluation and a head CT. Naranjo was not febrile, but his LP showed elevated protein and a low cerebrospinal fluid (CSF) pressure. His local doctors thought he might be suffering from aseptic meningitis, and hospitalized him for several weeks. A CT revealed nothing out of the ordinary. An MR scan showed bilateral subdural effusions and diffuse dural enhancement. A CT myelogram demonstrated that there was an accumulation of CSF outside C1-C2.

The diagnosis was spontaneous intracranial hypotension due to a CSF leak. But where was the leak? Location of the exact site of the leak is critical in guiding therapeutic decisions. The usual therapy for intracranial hypotension is to place a high-volume autologous blood patch at the leak site. But if the leak can't be located, such a therapy won't work well. Physicians in New Mexico tried blood patches, which worked only temporarily before the postural headaches would return.

Naranjo suffered nearly three years of on-and-off treatment in New Mexico. He was seldom upright for long. Finally, he came to UCSF Medical Center, where Dr. William Dillon and Dr. Robert Fishman evaluated him. Dillon performed a CT myelogram that revealed a C3-T10 extradural cyst and an accumulation of contrast media outside the dura at C1-C2. The clinical picture was of a long, bag-like intraspinal cyst that was filling with CSF. When the cyst was full of fluid, it would disgorge CSF at C1-C2. However, the presence of the cyst camouflaged the actual site of the leak, which could be anywhere along the cyst.

In general, CT myelography is the method of choice for finding the site of a dural fistula. For this case, however, the site of the leak was hidden by CSF accumulation in a long cyst. Dynamic CT myelography, in which the contrast media are injected while the patient is inside the CT scanner and undergoes repeated scans, would be required. Epidural contrast media can leak into several vertebral segments in the course of three to five minutes, so frequent scans are required.

These new studies localized the fistula to the T3-T4 region. An epidural blood patch at this site was temporarily successful, but a six-week follow-up revealed renewed leakage. Naranjo then underwent a 10-hour surgery by Dr. Philip Weinstein, a neurosurgeon who closed the fistula and obliterated the cyst.

After 12 days in bed, Naranjo was able to rise and resume his work. He has remained asymptomatic postoperatively for more than a year. He credits the diligent and methodical techniques of his physicians and their combined interests of neurology, neuroradiology and neurosurgery for his eventual recovery.

Dr. Robert Fishman may be contacted at (415) 476-4652. Dr. William Dillon may be contacted at (415) 353-1687. Dr. Philip Weinstein may be contacted at (415) 353-7500.

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