Structured Approach for Imaging and Treatment of Spontaneous Intracranial Hypotension: a Case-Based Review

Spontaneous intracranial hypotension (SIH) is an increasingly diagnosed condition typically characterized by orthostatic headache and other symptoms caused by a decrease in cerebrospinal fluid (CSF) volume. The initial imaging work-up for patients with high pretest probability of SIH begins with a brain MRI and total spine MRI. At our institution, if MRI demonstrates a spinal longitudinal extradural collection, dynamic CT myelography is performed to localize the CSF leak. Most spinal longitudinal extradural collections are ventral; thus, dynamic CT myelography is most commonly performed with the patient in the prone position to elucidate the site of leak. If a lateral or dorsal extradural CSF collection is evident on MRI, lateral decubitus digital subtraction myelography or lateral decubitus CT myelography could be performed to identify less-common sites of leak. If the MRI does not demonstrate an extradural CSF collection, then the patient undergoes a conventional myelogram. If the site of leak is not identified, this would typically be followed by bilateral lateral decubitus digital subtraction myelography. Treatment options are determined on the basis of the ability to accurately locate the site and type of leak. This review presents several SIH cases to elucidate the imaging modalities for diagnosis, management algorithm, and therapeutic options.

Learning Objectives: To understand the imaging findings, management algorithm, and treatment options for spontaneous intracranial hypotension.