A Worrisome Explanation
When the patient saw the M.R.I. result, she was alarmed. She had, the report said, something called brain sag. She wasn’t sure what that was, but it sounded bad. She left a message for the P.A., and when she didn’t hear back, she got scared. She called her P.C.P. and was referred to another neurosurgeon, this time at the Cleveland Clinic.
The patient’s first thought when she saw Dr. Mohammed Abdulrazzak at the Cleveland Clinic branch in Canton, Ohio, was that he was too young to be a doctor, much less a neurosurgeon. He introduced himself, then sat in the chair across from hers. “I hear you have a headache,” he said. She felt a sense of real interest from him as she told her story. She explained how terrible her headaches were when she was upright, when she laughed or even spoke. When she sneezed, the pain was unbelievable. And recently the headaches seemed to be affecting her memory as well. She had to write things down to keep herself from forgetting. The migraine medications did help, but the only thing that made her headaches almost completely subside was lying down. When she said this, she thought she saw just a hint of excitement in the young doctor’s eyes.
Brain sag, Abdulrazzak explained, was usually caused by the loss of some of the spinal fluid that cushions and supports the brain. When standing, gravity pulls the already-depleted fluid farther downward, stretching the pain-sensitive membranes and structures around the brain. Lying down eases that stretch immediately. The woman’s story was classic for the diagnosis: a headache that responds to posture almost like a light switch, in a way that tension headaches and migraines rarely do.
Abdulrazzak pointed to the black and white curves of her brain on the M.R.I. Even when she was lying down, her cerebellum was so low that it was almost touching the skull near the foramen magnum, the hole through which the spinal column emerged. That’s why her brain appeared to be sagging. He asked the patient if she had had any recent surgery or trauma. She hadn’t. Abdulrazzak wasn’t surprised. Many of these leaks are spontaneous, the cause never discovered.
The hardest part of this disease was finding the leak. In the necessary test, called a myelogram, contrast is injected into the space around the spinal column and a CT scan captures where it leaks out.