A woman’s persistent and debilitating headaches, initially suspected to be migraines or an aneurysm, were eventually diagnosed as brain sag caused by a spinal fluid leak, illustrating the complexities behind a rare neurological condition.

The patient first sought medical attention after experiencing severe headaches aggravated by upright posture, laughter, speaking, and sneezing, along with early memory impairment. Despite treatment with migraine medication and propranolol, her symptoms persisted. Initial brain imaging, including MRI and CT scans, ruled out aneurysm and vascular abnormalities but revealed an unusual downward displacement of her brain, described as “brain sag.”

Brain sag typically results from a loss of cerebrospinal fluid (CSF), which cushions and supports the brain. When CSF volume is reduced, gravity pulls the brain downward, stretching sensitive membranes and causing headaches that lessen when lying down. This positional characteristic led the patient’s care to be transferred to neurosurgeon Dr. Mohammed Abdulrazzak at the Cleveland Clinic branch in Canton, Ohio. After reviewing her clinical history and imaging, Dr. Abdulrazzak suspected a CSF leak despite no recent surgery or trauma, which are common triggers; many leaks occur spontaneously without known cause.

Detecting the precise location of a CSF leak can be challenging. The patient underwent an initial myelogram, a diagnostic procedure involving contrast injection into the spinal canal, which was painful and did not reveal the leak. A newer, more sensitive imaging technique, performed under general anesthesia to reduce discomfort, was recommended but deferred by the patient due to the manageable nature of her symptoms at the time.

However, over a year later, the woman’s condition worsened, with headaches intensifying and significantly impacting her daily life, including social activities and memory. Encouraged by a close friend, she returned to Dr. Abdulrazzak, who conducted a second, specialized myelogram with sedation. This procedure identified a small CSF leak at the level of the 10th thoracic vertebra, where spinal fluid was escaping into a tiny vein.

Two weeks after the diagnosis, Dr. Abdulrazzak performed a minimally invasive procedure to seal the leak. Using fluoroscopic guidance, he navigated a catheter through the patient’s thigh vein to the leak site and injected a sealing agent to close it. The patient was warned to expect headaches for about a week as her body adjusted spinal fluid production.

In the weeks following the procedure, her headaches gradually subsided, and her memory improved. Approximately six weeks later, the woman reengaged in normal activities, including social outings she had previously avoided. She reported no return of her headaches, a sign that the treatment had successfully addressed the underlying cause of her symptoms. This case highlights the diagnostic challenges and treatment options associated with spontaneous CSF leaks and brain sag, conditions that mimic more common headache disorders but require specialized care.