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A 41-year-old man presented with a sudden onset severe occipital headache, vomiting, neck stiffness and photophobia. He had been previously well, aside from chronic mid and lower back pain. There was no focal neurological deficit and a plain CT head scan was normal. Subsequent lumbar puncture (LP) was heavily bloodstained with analysis showing sequential increase in red blood cell count (144 000×106/L first tube and 225 000×106/L third tube). It was not possible to undertake testing for xanthochromia as the cerebrospinal fluid (CSF) supernatant was grossly haemolysed. We prescribed nimodipine for presumed intracranial subarachnoid haemorrhage. CT angiogram and a digital subtraction cerebral angiogram showed no intracranial vascular abnormality. His symptoms improved and we made a putative diagnosis of benign thunderclap headache. At this point, we attributed the bloodstained CSF to traumatic LP and he was discharged with analgesia and neurology follow-up.
Three weeks later he developed a 1-week history of new lumbar back pain, numbness of the sacrum and penis, shooting pains in the lower limbs, progressive constipation, involuntary flatus and urinary urgency. On readmission, he had lower limb weakness, brisk knee and ankle jerks and flexor plantar responses. He had a sensory level to pin prick at T12. His bladder was palpable with a postmicturition residual volume of 750 ml.
T2 weighted MRI spine showed oedema within the lower cord extending to the conus. There were multiple aberrant flow voids within the spinal canal, …
Contributors SN, SM and RSW prepared the initial manuscript. Imaging (figure 1), legend and references within the body to the radiological procedure were provided by PC. ND reviewed and edited aspects related to the neurosurgical management of the case. DM reviewed and edited aspects related to the neurological assessment and management within the case.
Competing interests None.
Provenance and peer review Not commissioned. Externally peer reviewed. This paper was reviewed by Richard Davenport, Edinburgh, UK.