To present a complex case of chronic headaches in a young woman with a history of Lyme disease, complicated by idiopathic intracranial hypertension (IIH), transverse sinus stenosis, and left temporal sulcus herniation into the left transverse sinus forming an encephalocele, further complicated by post-dural puncture headaches status post blood patch, highlighting the diagnostic and therapeutic challenges associated with intracranial pressure related disorders.

Initial CT imaging showed findings concerning posterior reversible encephalopathy syndrome (PRES) and an empty sella. MRI and MRV revealed left temporal sulcus herniation into the left transverse sinus forming an encephalocele, with possible extension into the arachnoid granulation at the right transverse–sigmoid junction secondary to IIH. Bilateral distal transverse sinus stenosis was also present. Lumbar puncture demonstrated an elevated opening pressure of 27 cm H2O. The patient developed post-dural puncture headaches with meningismus, which improved following an epidural blood patch. After discontinuing hormonal contraception and holding acetazolamide, cognitive function and vision improved, though headaches persisted intermittently.

This case underscores the complex relationship between IIH, venous sinus stenosis, and secondary encephalocele formation. The findings suggest a continuum driven by elevated intracranial pressure rather than isolated pathology. Comprehensive imaging interpretation and multidisciplinary care are essential for optimal outcomes.

p>