“Can I Talk To You Laying Down, Please?”

Title:“CanItalktoyoulayingdown,Please?” HISTORY: Previouslyhealthy13yofemalepresentingforaseverelysymptomaticconcussionafterfallingbackwardswhilehiking.Shewasuncertainifshehitherheaddirectlyornotanddeniedanylesionsonthebackofherhead.NoLOC.Patientendorsedheadachethatwasexacerbatedtoa10/10inseveritywhenstanding/sittingupand2/10whenlyingdown.Shealsoendorsedsevereneckpain,dizziness,cognitiveimpairment,nausea,tinnitus,andphotosensitivity. PHYSICALEXAMINATION: Patient was crying while standing/sitting up and had tenderness over occiputbilaterally with full neck range of motion and negative nuchal sign. Speechregular alert, awake, oriented x 3.Cranial nerves II through XII clinically intact.Normal gait without ataxia. hVOR/Saccades POS for symptoms. DIFFERENTIALDIAGNOSIS: 1.Cerebrospinal fluid leak- 2.Concussion- 3.Intra cranial bleed- 4-Carotid Dissection TESTS AND RESULTS: Brain MRI:Severe reduction in CSF and sagging brain consistent with acute spontaneous spinalleak. No mass or other structural findings.Spine MRI:Ruptured Lumbar arachnoid cyst and spinal leakVision testing:King Devick showed significant delay in saccadic movementsEyebox tracking test illustrates overall mild abnormal study with smooth pursuitsVestibular testing today:Significant sway abnormalities on force plate FINALWORKING DIAGNOSIS: Cerebrospinal fluid leakConcussion TREATMENT AND OUTCOMES: 1-Sent to ED where she had MRI brain/spine done and was diagnosed with acutecerebrospinal fluid leak2-Admitted for Epidural blood patch procedure.3-Orthostatic headaches resolved after the blood patch, however the patient continuedto have some vestibulocular symptoms with associated dizziness and mild cognitiveimpairment related to concussion.4-Post concussive symptoms were treated with a combination of return to learn plan,exertional rehab, and vestibular rehab with full resolution of symptoms in 3.5 weeks.