Figure 2.

This 48-year-old man complained of an invalidating Valsalva-related headache. (A) Preoperative MRI, T2-weight, sagittal view showing a CM-1.5. Osteodural decompression was performed, and the arachnoid was accidentally violated. The dural sac was repaired using biological graft and fibrin glue. (B) Postoperative MRI, T2-weight, sagittal view showing a deep extradural pseudomeningocele that was not evident at skin level. Conservative treatment was attempted at first. The headache continued to worsen, especially in orthostatism, and 4 months later, he underwent reoperation for duraplasty using autologous fascia lata. (C) Follow-up MRI, T2-weight, sagittal view obtained 9 months after reoperation. There was no evidence of CSF collection; however, the orthostatic pain improved, but the headache did not yet resolve. Adhesions may have developed between the autologous graft and the cerebellum (red arrow). A further surgical procedure was offered, but was refused by the patient. The final CCOS score was 12.