Significance of upper cervical epidural venous engorgement on head computed tomography in the initial diagnosis of spontaneous intracranial hypotension: patient series

Toshihide Takahashi Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Japan

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Kiyoyuki Yanaka Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Japan

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Hitoshi Aiyama Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Japan

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Minami Saura Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Japan

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Michihide Kajita Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Japan
Department of Neurology, Tsukuba Memorial Hospital, Tsukuba, Japan

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Nobuyuki Takahashi Department of Radiology, Tsukuba Memorial Hospital, Tsukuba, Japan; and

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Kuniyuki Onuma Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Japan

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Eiichi Ishikawa Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan

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BACKGROUND

Spontaneous intracranial hypotension (SIH) is a rare condition characterized by positional headache, for which contrast-enhanced magnetic resonance imaging (MRI) is the preferred diagnostic method. Although MRI reveals characteristic findings, head computed tomography (CT) is usually the first diagnostic step, but identifying features of SIH on CT is often difficult. This study was specifically designed to evaluate the utility of head CT in detecting upper cervical epidural venous engorgement as a sign of SIH.

OBSERVATIONS

Of 24 patients with SIH diagnosed between March 2011 and May 2023, 10 did not undergo upper cervical CT. In the remaining 14 patients, engorgement of the upper cervical epidural venous plexus was observed. CT detection rates were consistent with MRI for spinal fluid accumulation or dural thickening. After treatment, in 92.9% of patients, the thickness of the epidural venous plexus decreased statistically significantly from 4.8 ± 1.3 mm to 3.6 ± 1.2 mm.

LESSONS

This study suggests that upper cervical spine CT focused on epidural venous engorgement may be helpful in the initial diagnosis of SIH and may complement conventional MRI evaluation. Extending CT imaging to the upper cervical spine will improve the diagnostic accuracy of patients with positional headaches suspected to be SIH.

ABBREVIATIONS

CSF = cerebrospinal fluid; CT = computed tomography; MRI = magnetic resonance imaging; SIH = spontaneous intracranial hypotension

BACKGROUND

Spontaneous intracranial hypotension (SIH) is a rare condition characterized by positional headache, for which contrast-enhanced magnetic resonance imaging (MRI) is the preferred diagnostic method. Although MRI reveals characteristic findings, head computed tomography (CT) is usually the first diagnostic step, but identifying features of SIH on CT is often difficult. This study was specifically designed to evaluate the utility of head CT in detecting upper cervical epidural venous engorgement as a sign of SIH.

OBSERVATIONS

Of 24 patients with SIH diagnosed between March 2011 and May 2023, 10 did not undergo upper cervical CT. In the remaining 14 patients, engorgement of the upper cervical epidural venous plexus was observed. CT detection rates were consistent with MRI for spinal fluid accumulation or dural thickening. After treatment, in 92.9% of patients, the thickness of the epidural venous plexus decreased statistically significantly from 4.8 ± 1.3 mm to 3.6 ± 1.2 mm.

LESSONS

This study suggests that upper cervical spine CT focused on epidural venous engorgement may be helpful in the initial diagnosis of SIH and may complement conventional MRI evaluation. Extending CT imaging to the upper cervical spine will improve the diagnostic accuracy of patients with positional headaches suspected to be SIH.

ABBREVIATIONS

CSF = cerebrospinal fluid; CT = computed tomography; MRI = magnetic resonance imaging; SIH = spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is a condition in which cerebrospinal fluid (CSF) volume decreases because of continuous or intermittent leakage from the CSF space.1 It is estimated to occur in 5 of every 100,000 people, with women 2–5 times more likely to be affected than men.2,3 Although the susceptible age at onset is between 30 and 50 years, the disorder can also occur in children and the elderly.2 The primary and most prevalent symptom of SIH is headache. The typical headache is positional, bilateral, and occipitonuchal.1,4,5 Cochlear-vestibular symptoms are also common, including tinnitus, hypoacusia, and dizziness.6

The increase in intracranial venous blood volume and subdural fluid accumulation, which can include CSF and blood components, counterbalances the decrease in CSF volume. These alterations result in pachymeningeal thickening, pituitary hyperemia, dilated venous sinuses, and brain displacement with sagging of the cerebellar tonsils and brainstem.7–13 Evaluation of clinical symptoms and imaging of these changes can lead to the diagnosis of SIH. Contrast-enhanced head magnetic resonance imaging (MRI) showing dural thickening and spinal MRI showing fluid accumulation in the epidural space are essential for the diagnosis of SIH.14 Engorgement of the spinal epidural venous plexus on MRI is also considered a diagnostic sign.15

Head computed tomography (CT) is considered less valuable than MRI, because MRI often shows indirect signs of SIH, whereas CT is often normal.16 However, if imaging studies are deemed necessary to rule out secondary headaches, screening with noncontrast head CT is usually performed first. It would be very beneficial if the initial CT could help diagnose SIH. The imaging range of routine head CT often includes a portion of the upper cervical spine in the most caudal slice plane. With this in mind, we retrospectively examined whether head CT could help to diagnose SIH, with a particular focus on the upper cervical epidural venous engorgement.

Study Description

Design

We designed a single-center retrospective study. Twenty-four patients were diagnosed with SIH at our hospital from March 2011 to May 2023. All patients were treated for SIH with continuous epidural saline infusion therapy. We have already reported on the effectiveness of this method.17 Briefly, a catheter was inserted in the spinal epidural space, through which saline was continuously injected to minimize the intradural and extradural pressure gradients. This method is expected to reduce CSF leakage and lead to spontaneous fistula closure. All 24 patients who had undergone such treatment showed symptom improvement and no recurrences.

In 14 of those 24 patients, head CT scanning included the upper cervical spine before and after treatment. Head MRI was used to determine dural thickening, subdural hematoma, dilated venous sinuses, and pituitary hyperemia. CSF accumulation in the spinal epidural space was verified using spinal MRI. The imaging findings were evaluated by 5 neurosurgeons, 1 neurologist, and 1 radiologist, and the decision was made by majority vote in cases of disagreement. The thickness of the epidural venous plexus of the upper cervical spine was measured on axial CT slices at the same thickest part at the C1–2 vertebral level before and after treatment. Twenty patients, ages 20–50 years old, who had undergone CT for primary headache for reasons other than SIH and for whom the upper cervical epidural venous plexus could be measured, were used as a control group.

Statistical Analysis

Statistical analysis was performed with the Wilcoxon signed-rank-sum test using IBM SPSS Statistics software (version 27.0, IBM Corp.) to compare the thickness of the upper cervical epidural venous plexus before and after treatment. The difference was considered statistically significant when the p value was less than 0.05.

Results

Population

The data were obtained from 14 patients (7 men and 7 women) with a mean age of 46.8 ± 9.9 years. In those 14 (58.3%) of the initially examined 24 cases, CT coverage extended to the upper cervical spine level, allowing venous engorgement assessment before and after treatment. In the remaining 10 patients (41.7%), head CT did not include the upper cervical spine. Notably, the upper spinal epidural venous plexus is generally barely noticeable, but it was observable and even measurable in thickness in most of the patients with SIH included in this study. In 13 (92.9%) of 14 patients, the thickness of the epidural venous plexus decreased after treatment. The mean thickness of the upper cervical epidural venous plexus was significantly reduced from 4.8 ± 1.3 mm before treatment to 3.6 ± 1.2 mm after treatment (p = 0.001). The mean age of the 20 patients (12 men and 8 women) in the control group was 42.1 ± 8.9 years. The thickness of the upper cervical epidural venous plexus was 3.6 ± 0.5 mm, which was significantly thinner than in the pretreatment group (p = 0.024). Comparison with the post-treatment group showed no significant differences (p = 0.912; Fig. 1). Pre- to post-treatment CT intervals were 123.2 ± 99.1 days. A summary of the characteristics of the 14 patients is presented in Table 1.

FIG. 1
FIG. 1

Changes in the upper cervical epidural venous plexus thickness on CT before and after treatment. The thickness of the upper cervical epidural venous plexus decreased from 4.7 ± 1.3 mm before treatment to 3.6 ± 1.2 mm after treatment with a significant difference (p = 0.001). The thickness of the upper cervical epidural venous plexus in the control group was 3.6 ± 0.5 mm, which was significantly different from the pretreatment group (p = 0.024).

TABLE 1

Summary of characteristics of 14 patients whose CT scans included the upper cervical spine before and after spontaneous intracranial hypotension treatment

Case No.Age (yrs)SexThickness of High Cervical Spine Epidural Venous Plexus (mm)CT Interval (days)Contrast-Enhanced MRIDural ThickeningSubdural Hematoma/HygromaRt or Lt of Subdural Hematoma/HygromaVenous Sinus DilationPituitary EnlargementCSF Leakage into Spinal Epidural Space
Pre-onsetPre-TxPost-Tx
135M3.06.25.470++++
245FNA6.85.0212+++Bilat+
355FNA5.05.2107+++Bilat++
454FNA4.01.6257NA+++
544MNA5.23.9203++Bilat++
642MNA2.42.037+++Lt++
740FNA3.22.557++++
844FNA4.63.9352+++
964MNA4.22.8120+++Bilat+
1041M3.04.94.2147++++
1150FNA6.53.436++++
1262MNA5.24.831NA+Bilat+
1328FNA3.32.935NA+
1451MNA5.33.461NA+Bilat++

NA = Not applicable; Tx = treatment; − = no; + = yes.

MRI examination showed subdural hematomas in 7 patients (50.0%; 7 bilateral, 1 unilateral), venous sinus dilatation in 11 patients (73.3%), pituitary enlargement in 3 patients (21.4%), and CSF collection in the spinal epidural space in 13 patients (92.9%). Contrast-enhanced MRI was performed in 10 patients, and dural thickening was observed in 7 (70%). The detection rate of upper cervical epidural venous engorgement on CT was similar to that of fluid collection in the spinal canal or dural thickening on MRI. No tonsillar descent was observed in any of the patients.

In 2 of the 14 cases, head CT was performed before the onset of SIH for other reasons, such as head trauma or migraine. At that time, the upper cervical epidural venous plexus was thinner than at SIH onset. In the illustrative case described below (case 10), the epidural venous plexus became markedly thicker, leading to the diagnosis of SIH.

Illustrative Case 10

A 41-year-old man complained of headaches, which had lasted some time before his admission. Two years earlier, migraine had been diagnosed. Head CT performed at that time showed no abnormalities (Fig. 2A). The patient continued oral treatment with triptans, but at that time, headache occurred again without any apparent reason and initially appeared as a usual migraine attack. However, it worsened, and the triptans were ineffective, so the CT was repeated. There were no abnormal intracranial findings, but the upper cervical epidural venous plexus was dilated, and there was clear engorgement compared with the previous CT, so intracranial hypotension was suspected (Fig. 2B). During the interview, the patient described headaches as not pulsatile but worsening while standing. Thus, the symptoms suggested intracranial hypotension. Spinal MRI showed leakage of CSF into the spinal canal, and intracranial hypotension was confirmed. A catheter was inserted through the cervicothoracic junction, and the patient was treated with continuous saline infusions for 2 weeks, and the headache resolved. Post-treatment CT showed that the epidural venous plexus engorgement at the upper cervical level had disappeared (Fig. 2C).

FIG. 2
FIG. 2

Case 10. CT images 2 years before the onset of SIH (A), at the onset of SIH (B), and after treatment (C). The epidural venous plexus was barely noticeable before onset, engorged at onset, and again became unnoticeable after treatment. In this study, the thickest part of the epidural venous plexus was measured (white line, B).

CT images in 2 other representative cases (cases 2 and 4) are shown in Fig. 3.

FIG. 3
FIG. 3

Axial head CT in 2 representative cases: cases 2 (A and B) and 4 (C and D) before treatment (A and C) and after treatment (B and D). In both patients, the epidural venous plexus was engorged before treatment but not prominent after treatment. The white lines (A and C) indicate the thickest part of the upper cervical epidural venous plexus, which was measured in this study.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

We retrospectively reviewed the radiological findings of 14 patients with SIH who had undergone head CT, including the upper cervical spine level, before and after treatment. Engorgement of the epidural venous plexus, which is generally unnoticeable, was observed in all cases. In 13 of those 14 patients, the upper cervical epidural venous plexus became thinner after treatment. Although a difference of 1.2 mm may be of little symptomatic or clinical significance, the fact that venous engorgement, usually barely noticeable, was observed in patients with SIH seems important from a diagnostic imaging perspective. In the control group, the thickness of the upper cervical epidural venous plexus averaged 3.6 mm, whereas Yousry et al.18 reported a thickness of 3.3 mm for the epidural venous plexus at the C2 level. Both measurements were nearly equivalent. In 2 of the 14 patients, head CT was performed before the onset of SIH for other reasons, and the upper cervical epidural venous plexus was barely noticeable at that time. Therefore, the upper cervical epidural venous engorgement was induced by SIH and was attenuated by treatment. Although we could not find any reports focusing on CT findings of the epidural venous plexus of the upper cervical spine in the diagnosis of SIH or the evaluation of treatment efficacy, this study suggests that brain CT that includes the upper cervical spine level may be useful in the initial diagnosis of SIH and in determining treatment efficacy.

Although reformatted sagittal and coronal images are helpful in evaluating dilation of the dural venous sinuses and enlargement of the pituitary gland, the upper cervical epidural venous plexus is depicted well on axial images. The plexus is generally symmetrical and located in the lateral portion of the spinal canal; therefore, epidural venous engorgement is better visualized on axial than on sagittal or coronal CT images. Routine axial imaging could be sufficiently specific for the initial evaluation of SIH.

Observations

For patients presenting to a hospital with a chief complaint of headache, the most common examination to rule out secondary headache is head CT. However, the demonstration of dural thickening, pituitary enlargement, and venous sinus dilation, which are considered characteristic of SIH, on head CT is a challenge. In this study, the upper cervical epidural venous engorgement, considered one of the characteristic findings of SIH, was shown on routine head CT. In other words, when SIH is suspected on the basis of symptoms such as positional headache, including the upper cervical spine in the CT scan range will help to diagnose SIH.

MRI findings that are considered characteristic of SIH, such as dural thickening, venous sinus dilation, and pituitary enlargement, are explained by the Monro-Kellie doctrine, according to which the vascular space should expand as CSF volume decreases.19 It is unclear how long it takes for this change associated with decreased CSF volume to appear on imaging. According to some reports, typical findings are not observed in the acute phase of the disease, and it takes some time for them to appear.20,21 Therefore, multiple imaging findings should be evaluated rather than focusing on only one reference finding. However, it should be noted that even in this study, in 10 (41.7%) of 24 patients with SIH, the level of the upper cervical spine was not visualized on head CT. If SIH is suspected on the basis of clinical symptoms or other reference findings, head CT should be extended to the upper cervical spine level.

There are several limitations to this study. First, it is a single-center retrospective study with few cases. In the future, a larger sample size can be analyzed by conducting prospective studies at multiple treatment facilities, and the results will aid in the diagnosis and treatment of SIH. Second, as mentioned above, the reference findings characteristic of SIH may not be adequately accounted for, because they may not immediately appear in the acute phase. In some cases, MRI was performed only at the time of diagnosis, which may have allowed evaluation only before the typical changes appeared. Future studies with protocolized imaging over time may provide new insights into SIH reference findings. Third, the relationship between treatment and imaging changes has not been investigated. The imaging changes focused on in this paper are likely to occur regardless of the treatment modality. We treated the patient with continuous epidural saline infusion, but an epidural blood patch is the most common treatment. Future research may be needed regarding differences in treatment and imaging changes.

Lessons

Epidural venous engorgement in the upper cervical spine on CT, which was detected in most SIH cases in this study, may be helpful in the initial diagnosis of SIH. When performing brain CT for the initial diagnosis in a patient with positional headache suspected to be SIH, expanding the imaging range to the upper cervical spine may aid in the diagnosis.

Acknowledgments

The authors thank Dr. Alexander Zaboronok of the University of Tsukuba Institute of Medicine Department of Neurosurgery for language revision.

Author Contributions

Conception and design: T Takahashi, Yanaka, Aiyama, N Takahashi. Acquisition of data: Yanaka, Kajita, N Takahashi. Analysis and interpretation of data: T Takahashi, Kajita. Drafting the article: T Takahashi. Critically revising the article: Ishikawa, T Takahashi, Aiyama, Saura, Kajita. Reviewed submitted version of manuscript: Ishikawa, Aiyama, Kajita, Onuma. Approved the final version of the manuscript on behalf of all authors: Ishikawa. Statistical analysis: T Takahashi. Administrative/technical/material support: Aiyama, N Takahashi. Study supervision: Ishikawa, Yanaka, Aiyama.

Supplemental Information

Previous Presentations

Presented as a poster at the 82nd Meeting of the Japanese Neurosurgical Society, Yokohama, Japan, October 25, 2023.

References

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    Davidson B, Nassiri F, Mansouri A, et al. Spontaneous intracranial hypotension: a review and introduction of an algorithm for management. World Neurosurg. 2017;101:343349.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Lin JP, Zhang SD, He FF, Liu MJ, Ma XX The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain. 2017;18(1):4.

  • 3

    Schievink WI, Maya MM, Moser F, Tourje J, Torbati S Frequency of spontaneous intracranial hypotension in the emergency department. J Headache Pain. 2007;8(6):325328.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Jones MR, Shlobin NA, Dahdaleh NS Spontaneous spinal cerebrospinal fluid leak: review and management algorithm. World Neurosurg. 2021;150:133139.

  • 5

    Limaye K, Samant R, Lee RW Spontaneous intracranial hypotension: diagnosis to management. Acta Neurol Belg. 2016;116(2):119125.

  • 6

    Mokri B Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache. 2013;53(7):10341053.

  • 7

    Alcaide-Leon P, López-Rueda A, Coblentz A, Kucharczyk W, Bharatha A, de Tilly LN Prominent inferior intercavernous sinus on sagittal T1-weighted images: a sign of intracranial hypotension. AJR Am J Roentgenol. 2016;206(4):817822.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Beck J, Gralla J, Fung C, et al. Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients. J Neurosurg. 2014;121(6):13801387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Park ES, Kim E Spontaneous intracranial hypotension: clinical presentation, imaging features and treatment. J Korean Neurosurg Soc. 2009;45(1):14.

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    Savoiardo M, Minati L, Farina L, et al. Spontaneous intracranial hypotension with deep brain swelling. Brain. 2007;130(Pt 7):18841893.

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    Schievink WI, Maya MM, Nuño M Chronic cerebellar hemorrhage in spontaneous intracranial hypotension: association with ventral spinal cerebrospinal fluid leaks: clinical article. J Neurosurg Spine. 2011;15(4):433440.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Tian W, Zhang J, Chen J, Liu Y, Chen X, Wang N A quantitative study of intracranial hypotensive syndrome by magnetic resonance. Clin Neurol Neurosurg. 2016;141:7176.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Watanabe A, Horikoshi T, Uchida M, Koizumi H, Yagishita T, Kinouchi H Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neuroradiol. 2009;30(1):147151.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Starling A, Hernandez F, Hoxworth JM, et al. Sensitivity of MRI of the spine compared with CT myelography in orthostatic headache with CSF leak. Neurology. 2013;81(20):17891792.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Albayram S, Wasserman BA, Yousem DM, Wityk R Intracranial hypotension as a cause of radiculopathy from cervical epidural venous engorgement: case report. AJNR Am J Neuroradiol. 2002;23(4):618621.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Ferrante E, Trimboli M, Rubino F Spontaneous intracranial hypotension: review and expert opinion. Acta Neurol Belg. 2020;120(1):918.

  • 17

    Onuma K, Yanaka K, Nakamura K, et al. Continuous epidural saline infusion for the treatment of spontaneous intracranial hypotension. World Neurosurg. 2023;172:e640e645.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Yousry I, Förderreuther S, Moriggl B, et al. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. AJNR Am J Neuroradiol. 2001;22(7):12391250.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Mokri B The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology. 2001;56(12):17461748.

  • 20

    Fuh JL, Wang SJ Transtentorial herniation with cerebral infarction and duret haemorrhage in a patient with spontaneous intracranial hypotension: authors’ reply. Cephalalgia. 2008;28(4):410.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Kranz PG, Amrhein TJ, Choudhury KR, Tanpitukpongse TP, Gray L Time-dependent changes in dural enhancement associated with spontaneous intracranial hypotension. AJR Am J Roentgenol. 2016;207(6):12831287.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1

    Changes in the upper cervical epidural venous plexus thickness on CT before and after treatment. The thickness of the upper cervical epidural venous plexus decreased from 4.7 ± 1.3 mm before treatment to 3.6 ± 1.2 mm after treatment with a significant difference (p = 0.001). The thickness of the upper cervical epidural venous plexus in the control group was 3.6 ± 0.5 mm, which was significantly different from the pretreatment group (p = 0.024).

  • FIG. 2

    Case 10. CT images 2 years before the onset of SIH (A), at the onset of SIH (B), and after treatment (C). The epidural venous plexus was barely noticeable before onset, engorged at onset, and again became unnoticeable after treatment. In this study, the thickest part of the epidural venous plexus was measured (white line, B).

  • FIG. 3

    Axial head CT in 2 representative cases: cases 2 (A and B) and 4 (C and D) before treatment (A and C) and after treatment (B and D). In both patients, the epidural venous plexus was engorged before treatment but not prominent after treatment. The white lines (A and C) indicate the thickest part of the upper cervical epidural venous plexus, which was measured in this study.

  • 1

    Davidson B, Nassiri F, Mansouri A, et al. Spontaneous intracranial hypotension: a review and introduction of an algorithm for management. World Neurosurg. 2017;101:343349.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Lin JP, Zhang SD, He FF, Liu MJ, Ma XX The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain. 2017;18(1):4.

  • 3

    Schievink WI, Maya MM, Moser F, Tourje J, Torbati S Frequency of spontaneous intracranial hypotension in the emergency department. J Headache Pain. 2007;8(6):325328.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Jones MR, Shlobin NA, Dahdaleh NS Spontaneous spinal cerebrospinal fluid leak: review and management algorithm. World Neurosurg. 2021;150:133139.

  • 5

    Limaye K, Samant R, Lee RW Spontaneous intracranial hypotension: diagnosis to management. Acta Neurol Belg. 2016;116(2):119125.

  • 6

    Mokri B Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache. 2013;53(7):10341053.

  • 7

    Alcaide-Leon P, López-Rueda A, Coblentz A, Kucharczyk W, Bharatha A, de Tilly LN Prominent inferior intercavernous sinus on sagittal T1-weighted images: a sign of intracranial hypotension. AJR Am J Roentgenol. 2016;206(4):817822.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Beck J, Gralla J, Fung C, et al. Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients. J Neurosurg. 2014;121(6):13801387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Park ES, Kim E Spontaneous intracranial hypotension: clinical presentation, imaging features and treatment. J Korean Neurosurg Soc. 2009;45(1):14.

  • 10

    Savoiardo M, Minati L, Farina L, et al. Spontaneous intracranial hypotension with deep brain swelling. Brain. 2007;130(Pt 7):18841893.

  • 11

    Schievink WI, Maya MM, Nuño M Chronic cerebellar hemorrhage in spontaneous intracranial hypotension: association with ventral spinal cerebrospinal fluid leaks: clinical article. J Neurosurg Spine. 2011;15(4):433440.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Tian W, Zhang J, Chen J, Liu Y, Chen X, Wang N A quantitative study of intracranial hypotensive syndrome by magnetic resonance. Clin Neurol Neurosurg. 2016;141:7176.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Watanabe A, Horikoshi T, Uchida M, Koizumi H, Yagishita T, Kinouchi H Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neuroradiol. 2009;30(1):147151.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Starling A, Hernandez F, Hoxworth JM, et al. Sensitivity of MRI of the spine compared with CT myelography in orthostatic headache with CSF leak. Neurology. 2013;81(20):17891792.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Albayram S, Wasserman BA, Yousem DM, Wityk R Intracranial hypotension as a cause of radiculopathy from cervical epidural venous engorgement: case report. AJNR Am J Neuroradiol. 2002;23(4):618621.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Ferrante E, Trimboli M, Rubino F Spontaneous intracranial hypotension: review and expert opinion. Acta Neurol Belg. 2020;120(1):918.

  • 17

    Onuma K, Yanaka K, Nakamura K, et al. Continuous epidural saline infusion for the treatment of spontaneous intracranial hypotension. World Neurosurg. 2023;172:e640e645.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Yousry I, Förderreuther S, Moriggl B, et al. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. AJNR Am J Neuroradiol. 2001;22(7):12391250.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Mokri B The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology. 2001;56(12):17461748.

  • 20

    Fuh JL, Wang SJ Transtentorial herniation with cerebral infarction and duret haemorrhage in a patient with spontaneous intracranial hypotension: authors’ reply. Cephalalgia. 2008;28(4):410.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Kranz PG, Amrhein TJ, Choudhury KR, Tanpitukpongse TP, Gray L Time-dependent changes in dural enhancement associated with spontaneous intracranial hypotension. AJR Am J Roentgenol. 2016;207(6):12831287.

    • PubMed
    • Search Google Scholar
    • Export Citation

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