Diagnosis and Treatment of Spontaneous Intracranial Hypotension: Role of Epidural Blood Patching

Abstract

Purpose of review: This review focuses on the challenges of diagnosing and treating spontaneous intracranial hypotension (SIH), a condition caused by spinal CSF leakage. It emphasizes the need for increased awareness and advocates for early and thoughtful use of empirical epidural blood patches (EBPs) in suspected cases.

Recent findings: SIH diagnosis is hindered by variable symptoms and inconsistent imaging results, including normal brain MRI and unreliable spinal opening pressures. It is crucial to consider SIH in differential diagnoses, especially in patients with connective tissue disorders. Early EBP intervention is shown to improve outcomes.

Summary: SIH remains underdiagnosed and undertreated, requiring heightened awareness and understanding. This review promotes proactive EBP use in managing suspected SIH and calls for continued research to advance diagnostic and treatment methods, emphasizing the need for innovative imaging techniques for accurate diagnosis and timely intervention.

Figure 1. Classic “SEEPS” MRI Findings in Spontaneous Intracranial Hypotension

(A) Coronal T2 FLAIR image demonstrates bilateral subdural fluid collections (arrows). (B) Axial T1 postcontrast MRI demonstrates smooth circumferential pachymeningeal enhancement. (C) Sagittal T1 postcontrast MRI demonstrates venous engorgement (solid arrows), pituitary engorgement (dashed arrow), and sagging of the brainstem (bracket).

Figure 2. “Normal” Brain MRI in a Patient With SIH

(A) Axial T1 postcontrast MRI demonstrates no pachymeningeal enhancement or subdural collections. (B) Sagittal T1 MRI demonstrates no significant sagging of the brainstem. (C) Sagittal T2 STIR MRI demonstrates a posterior epidural fluid collection. (D) Axial 3D T2 fat-saturated image demonstrates abnormal epidural fluid surrounding the dura in the midthoracic spine. (E) Dynamic decubitus myelography demonstrates extravasation of subarachnoid contrast into the lateral epidural space at T9-T10 (arrow). (F) Intraoperative photograph during surgical repair demonstrates a lateral dural defect at T9-T10 along the axilla of the left T9 nerve root (arrows). Postoperative T2 fat-saturated imaging in the sagittal (G) and axial (H) planes shows resolution of the epidural fluid collection.

Figure 3. Conventional vs Decubitus Myelography in a Patient With CSF Venous Fistula

(A) Conventional myelogram at T6-7 demonstrates no evidence of CSF leak or CVF. (B) Dynamic decubitus CT myelography performed in the same patient demonstrates a CSF-venous fistula at T6-7 (arrow).