Cerebrospinal fluid leakage in a patient with depression: Pre-existing depression may complicate the clinical picture of this complex syndrome

Orthostatic headache is a key symptom of cerebrospinal fluid leakage. Other features may include neck pain, interscapular pain, nausea, vomiting, dizziness, tinnitus, and blurred vision. Various psychological or mental symptoms such as depression, forgetfulness, and a decreased power of concentration may also occur in this syndrome. When these symptoms are prominent or precede the onset of other symptoms, the clinical picture of this syndrome becomes more complicated, leading to misdiagnosis or long-term neglect. Of note, patients with cerebrospinal fluid leakage who visit an otolaryngological or oto-neurological clinic usually have atypical manifestations. In the vast majority of our patients with this syndrome, the presenting symptom is dizziness, not headache. The presenting symptom of the 30-year-old female patient who is the subject of this report was also dizziness. The patient's initial symptom was a stomachache; however, medical therapy was ineffective, and endoscopic examination of the stomach revealed no abnormalities. The stomachache was diagnosed as resulting from psychological or mental causes. Other manifestations also indicated that the patient suffered from mental depression. Antidepressants and sleeping pills were prescribed, but no improvement was noted. Dizziness, unsteadiness, nausea, and loss of concentration occurred insidiously and worsened after the patient hit her occiput strongly against a wall during an attack of hyperventilation. The patient also complained of headache. The patient was referred to our clinic by a local otolaryngologist. At the time of the patient's initial visit, a slight unsteadiness was noted while the patient stood and walked, but other vestibular functions were normal. A neurological examination did not show any abnormalities. Psychological testing confirmed the presence of depression. The patient, presumably because of her depression, was dispirited and never discussed her symptoms voluntarily. However, a detailed history revealed that the patient had an orthostatic headache, paresthesia in both hands, blurred vision, and forgetfulness. Several episodes of falls at a pool-side occurring as early as during elementary school were also noted. The diagnosis of cerebrospinal fluid leakage was confirmed by brain MRI and ¹¹¹In- cisternography examinations. An epidural blood patch was performed three times. The patient recovered from her depression; although a mild headache and nausea persisted, all the patient's other symptoms, including dizziness and unsteadiness, improved dramatically. The patient returned to work.