Post-dural puncture pseudomeningocele (“arachnoid bleb”): An underrecognized etiology of spontaneous intracranial hypotension symptomatology

Spontaneous intracranial hypotension (SIH) is an important secondary cause of a persistent headache syndrome, classically presenting as sudden onset debilitating positional headaches related to reduced intracranial cerebrospinal fluid (CSF) volume. Current understanding of SIH pathogenesis recognizes three underlying etiologies: dural tear, meningeal diverticulum, and CSF-venous fistula, with a fourth broad category of indeterminate/unknown etiologies. Post-dural puncture headache (PDPH) is a well-known and common complication of dural puncture, typically remitting spontaneously within two weeks of onset or with autologous epidural blood patch, though with some patients developing complex and difficult to manage chronic PDPH. Herein, we present a case of chronic PDPH resulting in SIH symptomatology secondary to a post-dural puncture pseudomeningocele, or “arachnoid bleb,” successfully treated with curative surgical intervention. Increasing awareness of additional potential etiologies of SIH symptomatology will allow for improved detection for targeted definitive therapy, ultimately improving patient outcomes including quality of life in this debilitating and difficult to manage secondary headache syndrome. •PDPH is a well-known and common complication of dural puncture/neuraxial anesthesia, with a reported incidence of 10-40%.•While PDPH typically remits spontaneously or with autologous EBP, chronic cases can become complex and difficult to manage.•We present a case of a post-dural puncture arachnoid bleb resulting in SIH, treated with curative surgical intervention.•Increasing awareness of etiologies of SIH allows for improved detection for definitive treatment and improved outcomes.