Beyond the Headaches: Severe Dysphagia As the Dominant Symptom of Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is a rare but recognized condition that usually presents with orthostatic headache, brain sagging, and meningeal enhancement on an MRI. However, atypical presentations with a wide range of neurological symptoms are possible. Dysphagia is rarely documented as a dominant symptom in SIH. We present the case of a 50-year-old male patient with progressive slurred speech, facial weakness, gait instability, and severe swallowing dysfunction. Initial CT and MRI imaging revealed cerebellar tonsillar herniation and a left paravermian cyst, suggesting possible SIH in the background of a Chiari malformation. The definitive diagnosis of intracranial hypotension was made with brainstem sagging and meningeal enhancement seen on MRI with IV contrast. No evidence of a cerebrospinal fluid (CSF) leak was found on serial imaging, including a CT myelogram. The patient experienced severe and clinically significant pharyngeal dysphagia, confirmed on videofluoroscopy, with recurrent aspiration and the need for prolonged nasogastric feeding. Initially, he was managed with hydration, caffeine, and adequate bed rest without improvement. Input from neurology, neurosurgery, and SIH multidisciplinary (MDT) teams from tertiary centers was sought, with a plan for a blind lumbar epidural blood patch. However, the patient showed spontaneous clinical improvement over the course of admission and was discharged with outpatient neurology follow-up. This case illustrates the diagnostic challenges of SIH in the absence of demonstrable CSF leak and reinforces the consideration of SIH in the differential diagnosis of acquired Chiari-malformation-like radiological findings.