The cumulative presence of these intracranial findings has been shown to correlate with a likelihood of finding a spinal leak source [16]. The spinal imaging findings associated with SIH include direct evidence of CSF leakage via epidural fluid collections and CSF-venous fistula as well as secondary indirect signs of CSF leakage such as dilated epidural venous plexus, subdural hygromas, and dural enhancement [24,28-30]. It should be noted that CSF pressure can be normal in patients with SIH, and the absence of a low CSF pressure should not exclude this condition [31,32]. It also bears mentioning that the diagnosis of SIH is challenging, and in some cases SIH cannot be definitely diagnosed or excluded until a full diagnostic workup with invasive imaging (myelography) has been performed. In cases in which symptoms persist after a negative full imaging workup, the possibility of SIH mimicking pathologies such as positional orthostatic tachycardia syndrome, cervicogenic headaches, migraines, or new daily persistent headache syndromes should be considered [33]. Using the best available evidence, this document provides diagnostic imaging recommendations for intracranial hypotension across various clinical presentations. In cases in which conservative/medical management or a therapeutic procedural intervention may be a more appropriate first step over imaging, the evidence to support such practices is discussed in the variant narrative. OR Discussion of Procedures by Variant Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging. This clinical scenario refers to a patient who demonstrates postural orthostatic headaches with or without additional secondary SIH symptoms.
Imaging of Suspected Intracranial Hypotension PCAs. The cumulative presence of these intracranial findings has been shown to correlate with a likelihood of finding a spinal leak source [16]. The spinal imaging findings associated with SIH include direct evidence of CSF leakage via epidural fluid collections and CSF-venous fistula as well as secondary indirect signs of CSF leakage such as dilated epidural venous plexus, subdural hygromas, and dural enhancement [24,28-30]. It should be noted that CSF pressure can be normal in patients with SIH, and the absence of a low CSF pressure should not exclude this condition [31,32]. It also bears mentioning that the diagnosis of SIH is challenging, and in some cases SIH cannot be definitely diagnosed or excluded until a full diagnostic workup with invasive imaging (myelography) has been performed. In cases in which symptoms persist after a negative full imaging workup, the possibility of SIH mimicking pathologies such as positional orthostatic tachycardia syndrome, cervicogenic headaches, migraines, or new daily persistent headache syndromes should be considered [33]. Using the best available evidence, this document provides diagnostic imaging recommendations for intracranial hypotension across various clinical presentations. In cases in which conservative/medical management or a therapeutic procedural intervention may be a more appropriate first step over imaging, the evidence to support such practices is discussed in the variant narrative. OR Discussion of Procedures by Variant Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging. This clinical scenario refers to a patient who demonstrates postural orthostatic headaches with or without additional secondary SIH symptoms.