Concussion Misdiagnosis Example

A woman in her mid-30s was rear-ended. There was not a lot of damage to the rear of her vehicle, and many were shocked that she was suffering symptoms of early confusion, dizziness, headaches, and neck pain. She remembers struggling in the grocery store shortly after the crash and had trouble completing her thoughts.

In the following hours, days, and weeks other symptoms were noted, including a burning sensation in the face, headaches around her eyes (periorbital pain), jaw pain, tooth pain, and a feeling of weakness in her neck. She was also experiencing an abnormal sensation of tightness in the neck and shoulders, and she felt like the sensation in her arms and hands wasn’t right.

After 3 years and seeing various doctors, she was still stuck with the diagnosis of “brain injury.” The reality, however, is that some of her symptoms were clues that this was not a concussion or brain injury at all. Sometimes it’s easier to know what someone doesn’t have than what they do have. There was a suggestion of some underlying orthostatic symptoms (her headaches would generally improve after laying down and worsen the longer she was upright) and this lead to some “homework” that she readily completed.

Miraculously, virtually all of her symptoms resolved during the homework, and for 2-3 days afterward she felt normal again. Not surprisingly, her symptoms returned to their prior levels again, but now the clinical diagnosis was obvious. This patient was suffering from a traumatic spinal CSF leak.

New imaging was ordered and confirmed a large spinal fluid leak extending from the upper neck down to her low back.


Figure 1. T2 weighted cervical MRI. Mid sagittal and axial images showing a ventral spinal fluid collection starting at about T2 and extending into the upper back.

Misdiagnosed Concussion MRR LX T2 SAG and Axial
Figure 2. T2 weighted lumbar MRI. Mid sagittal and axial images showing extradural collections of spinal CSF.

MRI images
Figure 3. Sagittal and axial images from the thoracic CT myelogram showing large collections of spinal fluid outside of the thecal sac.

With a correct diagnosis, this patient has new and different treatment options open to her. We are now working with local and national experts to coordinate her recovery.

 

Some of her symptoms associated with spinal CSF leaks:

Spinal CSF leaks have been documented to cause the symptoms she has been suffering from, including:

Headaches1-12

Cognitive difficulties5, 7

Face symptoms7, 11

Neck pain and tightness5, 7-15

Abnormal sensation in the extremities7, 9, 11

 

If you’ve been injured in a crash and are suffering from headaches, neck, back pain, or think you’ve been misdiagnosed, please give our clinic a call at 503-774-3778.

References

  1. Mokri, B., Spontaneous CSF leaks: low CSF volume syndromes. Neurol Clin, 2014. 32(2): p. 397-422.
  2. Eross, E.J., et al., Orthostatic headache syndrome with CSF leak secondary to bony pathology of the cervical spine. Cephalalgia, 2002. 22(6): p. 439-43.
  3. Mokri, B., D.G. Piepgras, and G.M. Miller, Syndrome of orthostatic headaches and diffuse pachymeningeal gadolinium enhancement. Mayo Clin Proc, 1997. 72(5): p. 400-13.
  4. Graf, N., et al., Clinical symptoms and results of autonomic function testing overlap in spontaneous intracranial hypotension and postural tachycardia syndrome:A retrospective study. Cephalalgia Reports, 2018. 1: p. 2515816318773774.
  5. Renowden, S., et al., Spontaneous intracranial hypotension. Journal of neurology, neurosurgery, and psychiatry, 1995. 59: p. 511-5.
  6. Inamo, Y., A boy with growth disturbance caused by hypothalamic damage associated with intracranial hypotension syndrome following a motor vehicle accident: case report. Endocr J, 2008. 55(6): p. 1113-6.
  7. Schievink, W.I., Misdiagnosis of spontaneous intracranial hypotension. Archives of Neurology, 2003. 60(12): p. 1713-1718.
  8. Davies, M.J., et al., Epidural blood patch as a diagnostic and therapeutic intervention in spontaneous intracranial hypotension: a novel approach to management. World neurosurgery, 2020. 137: p. e242-e250.
  9. Akiba, C., et al., Cerebrospinal fluid leak presented with the C1-C2 sign caused by spinal canal stenosis: a case report. BMC neurology, 2020. 20(1): p. 1-5.
  10. Fishman, R.A. and W.P. Dillon, Dural enhancement and cerebral displacement secondary to intracranial hypotension. Neurology, 1993. 43(3 Part 1): p. 609-609.
  11. Mokri, B. and J.B. Posner, Spontaneous intracranial hypotension: the broadening clinical and imaging spectrum of CSF leaks. 2000, AAN Enterprises. p. 1771-1772.
  12. Mokri, B., Spontaneous CSF leaks mimicking benign exertional headaches. Cephalalgia, 2002. 22(10): p. 780-783.
  13. Ishikawa, S., et al., Epidural blood patch therapy for chronic whiplash-associated disorder. Anesth Analg, 2007. 105(3): p. 809-14.
  14. Morgan, J.T., et al., Case report: spontaneous intracranial hypotension in association with the presence of a false localizing C1-C2 cerebrospinal fluid leak. Surgical neurology, 2008. 70(5): p. 539-543.
  15. Clarot, F., et al., Giant cervical epidural veins after lumbar puncture in a case of intracranial hypotension. American journal of neuroradiology, 2000. 21(4): p. 787-789.
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