Spontaneous intracranial hypotension: updates from diagnosis to treatment

Paul J. Farnsworth, Ajay A. Madhavan, Jared T. Verdoorn, Darya P. Shlapak, Derek R. Johnson, Jeremy K. Cutsforth-Gregory, Waleed Brinjikji, Vance T. Lehman

Research output: Contribution to journalReview articlepeer-review


Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks, which result in continued loss of CSF volume and multiple debilitating clinical manifestations. The estimated annual incidence of SIH is 5/100,000. Diagnostic methods have evolved in recent years due to improved understanding of pathophysiology and implementation of advanced myelographic techniques. Here, we synthesize recent updates and contextualize them in an algorithm for diagnosis and treatment of SIH, highlighting basic principles and points of practice variability or continued debate. This discussion includes finer points of SIH diagnosis, CSF leak classification systems, less common types and variants of CSF leaks, brain MRI Bern scoring, potential SIH complications, key technical considerations, and positioning strategies for different types of dynamic myelography. The roles of conservative measures, non-targeted or targeted blood patches, surgery, and recently developed endovascular techniques are presented.

Original languageEnglish (US)
Pages (from-to)233-243
Number of pages11
Issue number2
StatePublished - Feb 2023


  • CSF leak
  • Digital subtraction myelography
  • Dynamic CT myelography
  • Orthostatic headache
  • Sponaneous intracranial hypotension
  • Tranvenous Onyx embolization

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine


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