Spontaneous Intracranial Hypotension: MRI Findings, Orthostatic Headache, CSF Leak Diagnosis, and Treatment

Edited by ScholarGen MediAI Team

Why This Case Matters

A new headache that becomes worse when standing and improves when lying down should not automatically be attributed to migraine or tension-type headache. When orthostatic headache is accompanied by dizziness and a characteristic constellation of brain MRI findings, spontaneous intracranial hypotension (SIH) should be considered.

The key radiologic lesson is that SIH is rarely a “single-finding diagnosis.” Diffuse pachymeningeal enhancement, subdural collections, venous engorgement, pituitary enlargement, and brain sagging are best understood as interconnected consequences of reduced cerebrospinal fluid (CSF) volume.

This case illustrates an important workflow principle: the brain MRI may reveal the syndrome, but the underlying CSF leak is often located in the spine. The diagnostic process therefore needs to move from intracranial pattern recognition to spinal leak localization and, when appropriate, targeted treatment.

Executive Answer

Spontaneous intracranial hypotension (SIH) is a disorder usually related to spinal CSF leakage or a CSF-venous fistula, producing reduced intracranial CSF volume and compensatory venous changes. The most useful brain MRI clues include diffuse pachymeningeal enhancement, subdural collections or hematoma, venous sinus engorgement, pituitary enlargement, and brain sagging. In this case, the combination of three weeks of orthostatic headache and dizziness with these MRI findings strongly supports SIH. Because brain MRI may not localize the actual leak, the next diagnostic step is generally spinal imaging, followed, when indicated, by CT myelography or digital subtraction myelography.

Clinical Scenario

A woman in her early 40s developed approximately three weeks of orthostatic headache and dizziness.

The brain MRI demonstrated:

Diffuse pachymeningeal enhancement
Bilateral subdural collections
A left subdural hematoma
Pituitary enlargement
Inferior displacement of the cerebellar tonsils
Right transverse sinus enlargement
Reduced CSF within the optic nerve sheath
No definite focal brain parenchymal signal abnormality
No significant midline shift

The combination is much more informative than any single abnormality.

The central diagnostic question is therefore not simply, “Is there a low-lying cerebellar tonsil?” or “Is the pituitary enlarged?” Instead, the radiologist should ask:

Do these findings form a coherent pattern of reduced intracranial CSF volume?

In this case, they do.

What Is Spontaneous Intracranial Hypotension?

Despite its name, SIH is fundamentally a disorder of CSF volume, rather than simply a persistently low measured CSF pressure.

CSF provides buoyant support for the brain. When CSF volume decreases because of spinal leakage or a CSF-venous fistula, the intracranial compartment undergoes compensatory changes.

The resulting pattern may include:

Venous enlargement and congestion
Diffuse pachymeningeal enhancement
Relative enlargement of the pituitary gland
Downward displacement of intracranial structures
Subdural fluid collections
Subdural hemorrhage in some patients

These findings are therefore not independent abnormalities. They can represent different manifestations of the same underlying reduction in CSF volume.

Why Does Orthostatic Headache Occur?

Orthostatic headache is one of the most important clinical clues to SIH.

Typically, the headache becomes worse after sitting or standing and improves after lying down. However, the temporal relationship is not identical in every patient. Some patients experience symptoms after remaining upright for an extended period rather than immediately after standing.

This distinction matters.

A patient whose current headache is no longer strongly positional may still have had a distinctly orthostatic headache at disease onset. Clinical history should therefore address:

How the headache behaved when it first began
Whether standing aggravated the symptoms
Whether lying down improved them
How quickly symptoms improved after recumbency
Whether dizziness, tinnitus, hearing changes, or neck pain accompanied the headache

Associated manifestations may include dizziness, imbalance, neck stiffness, posterior head pain, tinnitus, aural fullness, hearing changes, nausea, vomiting, fatigue, and impaired concentration.

The SEEPS Pattern on Brain MRI

A practical way to remember the major MRI manifestations of SIH is SEEPS:

S — Subdural collections: subdural fluid or hematoma
E — Enhancement of the pachymeninges: diffuse pachymeningeal enhancement
E — Engorgement of venous structures: enlarged dural venous sinuses and veins
P — Pituitary enlargement
S — Sagging of the brain: downward displacement of intracranial structures, including the cerebellar tonsils

The presence of several of these findings together substantially increases suspicion for reduced CSF volume.

Reduced CSF within the optic nerve sheath can provide an additional supportive clue.

Figure 1. Diffuse Pachymeningeal Enhancement

Caption: Axial T1-weighted post-contrast MRI demonstrates diffuse pachymeningeal enhancement along the cerebral hemispheres, a characteristic intracranial manifestation of spontaneous intracranial hypotension.

Radiologic interpretation: Diffuse rather than focal dural enhancement should prompt evaluation for the broader SIH pattern, particularly when subdural collections, venous enlargement, or brain sagging are also present.

Clinical significance: Pachymeningeal enhancement may reflect venous congestion and dural vascular changes associated with reduced CSF volume. However, infection, inflammatory dural disease, and dural metastatic disease can also produce dural enhancement. Pattern recognition must therefore be combined with clinical context.

Figure 2. Left Subdural Hematoma

Caption: Axial diffusion-weighted imaging demonstrates abnormal signal along the left cerebral convexity corresponding to a subdural hematoma, without significant midline shift.

Radiologic interpretation: The subdural space should be assessed for both fluid collections and hemorrhage. The size of the collection and its effect on adjacent brain structures are clinically important.

Clinical significance: A subdural hematoma may be a complication of SIH. DWI alone should not be used to determine the precise age of a hematoma; T1, T2, FLAIR, SWI, and other sequences should be reviewed together.

Figure 3. Pituitary Enlargement and Low-Lying Cerebellar Tonsils

Caption: Sagittal T2-weighted MRI demonstrates relative pituitary enlargement and inferior positioning of the cerebellar tonsils, supporting a brain-sagging pattern associated with reduced CSF volume.

Radiologic interpretation: Pituitary enlargement should be interpreted in relation to the surrounding venous structures and other SIH findings rather than immediately attributed to a pituitary adenoma.

The cerebellar tonsils should also be evaluated together with the brainstem, basal cisterns, and other signs of downward displacement.

Figure 4. Brain Sagging Pattern

Caption: Sagittal FLAIR MRI demonstrates inferior displacement of the cerebellar tonsils with associated intracranial structural changes compatible with brain sagging.

Clinical significance: Brain sagging is more meaningful when it occurs together with orthostatic headache, diffuse pachymeningeal enhancement, venous enlargement, or subdural collections.

Figure 5. Subdural Collection

Caption: Coronal T1-weighted MRI demonstrates abnormal signal within the subdural space along the cerebral convexity.

Radiologic interpretation: The distribution and thickness of subdural collections should be assessed, including whether the process is bilateral and whether there is significant mass effect or midline displacement.

Figure 6. Post-Contrast Assessment

Caption: Coronal T1-weighted post-contrast MRI demonstrates dural and venous enhancement patterns that should be interpreted in conjunction with the other findings of suspected spontaneous intracranial hypotension.

Figure 7. Subdural Hemorrhage on SWI

Caption: Axial susceptibility-weighted imaging demonstrates abnormal susceptibility signal within the left subdural space, consistent with subdural hemorrhage.

Clinical significance: SWI is sensitive to blood products and susceptibility differences, but imaging signal alone does not establish the precise age of a hematoma.

Radiologist's Reasoning: Why the Combination Matters

The most important feature of this case is not any individual MRI abnormality.

The meaningful pattern is:

Orthostatic headache + diffuse pachymeningeal enhancement + subdural collections + venous enlargement + pituitary enlargement + brain sagging

This constellation is substantially more persuasive for SIH than isolated tonsillar ectopia or isolated pituitary enlargement.

A useful reporting approach is to recognize the pattern first and then ask whether the findings can be explained by a common mechanism.

In this case, reduced CSF volume provides that unifying mechanism.

Why the Finding Can Be Missed

SIH can be overlooked for several reasons.

First, the presenting symptom may resemble a common primary headache disorder.

Second, individual MRI findings can mimic other diseases. Low-lying cerebellar tonsils may resemble Chiari I malformation, while pituitary enlargement may raise concern for a sellar lesion.

Third, the most obvious abnormality may distract from the broader pattern. A radiologist may focus on a subdural hematoma, pituitary enlargement, or tonsillar ectopia without integrating the remaining findings.

Fourth, not every patient has the classic combination of symptoms and MRI abnormalities.

Therefore, the diagnostic task is not simply to identify a single “signature sign.” It is to recognize a coherent pattern.

Differential Diagnosis

Chiari I Malformation

Low-lying cerebellar tonsils can occur in Chiari I malformation, making this an important differential diagnosis.

The distinction should not be made solely from the position of the tonsils.

In SIH, the tonsillar descent may be acquired as part of global brain sagging. Additional clues include diffuse pachymeningeal enhancement, venous sinus enlargement, subdural collections, brainstem descent, and narrowed basal cisterns.

Inflammatory or Infectious Pachymeningeal Disease

Diffuse dural enhancement is not specific for SIH.

Infectious or inflammatory dural disease may produce similar enhancement. Fever, systemic inflammatory symptoms, laboratory findings, and the morphology and distribution of dural thickening may help distinguish these entities.

The presence of orthostatic headache and multiple CSF-volume-loss signs supports SIH, but does not automatically exclude other pathology.

Dural Metastatic Disease

Dural metastases can also produce enhancement and dural thickening.

A history of malignancy, focal or nodular dural abnormalities, associated intracranial lesions, and findings elsewhere in the body should be considered when clinically appropriate.

Pituitary Adenoma

Pituitary enlargement in SIH may result from venous congestion and should not automatically be interpreted as a pituitary adenoma.

A true sellar mass may show focal enlargement, asymmetry, a discrete mass, or local mass effect. The morphology and enhancement pattern should be considered together with endocrine manifestations and the other MRI findings.

Chronic Subdural Hematoma

Subdural hematoma has many possible causes, including trauma, anticoagulation, and bleeding disorders.

However, an atraumatic subdural hematoma accompanied by orthostatic headache and other signs of reduced CSF volume should prompt consideration of a CSF leak.

Treating the hematoma alone may not address the underlying mechanism.

Cerebral Venous Thrombosis

Venous changes are common in SIH, but cerebral venous thrombosis remains an important potential complication.

If headache changes abruptly or new neurologic symptoms develop, CT venography or MR venography may be appropriate depending on the clinical situation.

In this case, no dural venous sinus thrombosis was identified on the available imaging.

Diagnostic Workup: From Brain MRI to Spinal Leak Localization

Brain MRI can establish a strong suspicion for SIH, but it often does not show the actual site of CSF leakage.

The diagnostic pathway therefore extends beyond the brain.

Step 1: Brain MRI

Contrast-enhanced brain MRI is particularly useful for evaluating:

Pachymeningeal enhancement
Subdural collections
Venous sinus enlargement
Pituitary enlargement
Brain sagging
Cerebellar tonsillar descent
Other supportive signs of reduced CSF volume

Step 2: Whole-Spine MRI

Whole-spine MRI can identify extradural CSF collections and other spinal abnormalities and may help determine the next diagnostic strategy.

However, a negative spinal MRI does not necessarily exclude a CSF leak or CSF-venous fistula.

Step 3: CT Myelography or Digital Subtraction Myelography

Depending on the spinal MRI findings, clinical course, and suspected leak type, CT myelography or digital subtraction myelography (DSM) may be considered.

These techniques can help localize abnormal CSF egress and may be particularly important when a fast leak or CSF-venous fistula is suspected.

The imaging strategy should be individualized rather than applied as a rigid sequence to every patient.

The Role of the Bern Score

The Bern score is an imaging-based supportive tool for estimating the probability of SIH.

It incorporates several MRI findings associated with reduced CSF volume, including:

Subdural collections
Pachymeningeal enhancement
Venous sinus enlargement
Pituitary enlargement
Brain sagging

The important limitation is that the Bern score estimates the likelihood of SIH; it does not directly localize the CSF leak.

Clinical judgment and spinal imaging remain essential when planning further diagnostic and therapeutic procedures.

Does a Normal Lumbar Puncture Pressure Exclude SIH?

No.

A normal CSF opening pressure does not by itself exclude spontaneous intracranial hypotension.

Moreover, lumbar puncture is not necessarily required in every patient with a convincing clinical and imaging pattern. An invasive procedure should have a clear clinical purpose rather than being performed simply to obtain a pressure measurement.

Treatment: How Is the CSF Leak Managed?

The therapeutic goal is not merely to suppress headache.

The objective is to control the underlying CSF leakage when possible and restore a more normal CSF-volume state.

Conservative Management

In selected patients with relatively mild and stable symptoms, clinicians may consider temporary activity modification, hydration, and symptomatic treatment.

However, prolonged bed rest is not universally effective. Persistent symptoms or substantial imaging abnormalities should prompt specialist assessment and consideration of definitive treatment.

Epidural Blood Patch

An epidural blood patch (EBP) is an important treatment option for SIH.

Autologous blood is injected into the epidural space with the goal of reducing or sealing CSF leakage.

When the exact leak location is not known, a non-targeted blood patch may be considered. When the leak has been localized, targeted treatment may be more appropriate.

Response varies among patients, and some require additional procedures.

Targeted Treatment and Surgery

When symptoms persist after blood patching or a specific leak site is identified, targeted treatment may be considered.

Depending on the leak mechanism, treatment can include:

Image-guided targeted patching
Treatment directed at a CSF-venous fistula
Endovascular approaches in selected situations
Surgical repair of a focal dural defect

The underlying leak mechanism matters because a dural tear and a CSF-venous fistula are not the same pathophysiologic problem.

What If a Subdural Hematoma Is Present?

Management should consider both the hematoma and the underlying CSF leak.

A small, clinically stable subdural hematoma without significant mass effect may sometimes be observed while the CSF leak is addressed.

A larger hematoma, significant mass effect, altered consciousness, or new focal neurologic deficits may require neurosurgical evaluation and possible drainage.

Treating the hematoma without addressing the underlying CSF leak may leave the mechanism responsible for recurrence unresolved.

Diagnostic Risk: Where Can Errors Occur?

This case demonstrates several potential system-level diagnostic vulnerabilities.

Anchoring on a Common Headache Diagnosis

A patient with headache and dizziness may initially be considered to have migraine or another primary headache disorder.

The diagnostic risk increases when the positional nature of the headache is not recognized.

Satisfaction of Search

Once a subdural hematoma is identified, the reader may stop searching for the underlying cause.

In an atraumatic patient with orthostatic symptoms, the hematoma itself should trigger consideration of a CSF-volume-loss mechanism.

Overcalling Individual Findings

Tonsillar descent can lead to an isolated diagnosis of Chiari I malformation.

Pituitary enlargement can lead to an isolated diagnosis of pituitary pathology.

Diffuse dural enhancement can lead to an isolated inflammatory or neoplastic differential.

The solution is pattern integration.

Incomplete Imaging Field-of-View Review

The clinical problem may originate in the spine even though the first major imaging abnormalities are intracranial.

A brain MRI that suggests SIH should therefore prompt consideration of the spinal compartment.

AI Perspective: Where Could Medical AI Help?

AI can potentially support SIH diagnosis, but the appropriate role is decision support rather than autonomous diagnosis.

A clinically useful radiology AI system could potentially assist with:

Detection of diffuse pachymeningeal enhancement
Recognition or quantification of subdural collections
Identification of venous sinus enlargement
Measurement of cerebellar tonsillar position
Recognition of brain-sagging patterns
Structured comparison with prior MRI studies
Flagging combinations of findings that warrant radiologist review

The most interesting opportunity is not detecting one abnormality in isolation.

It is multi-feature pattern recognition.

For example:

Pachymeningeal enhancement + subdural collection + venous enlargement + pituitary enlargement + brain sagging → increased suspicion for reduced CSF volume

This type of multimodal reasoning could potentially help reduce perceptual misses in high-volume radiology workflows.

However, such an AI system would require rigorous clinical validation.

AI Failure Modes

AI support could fail through:

False-negative detection
False-positive findings
Poor image quality
Anatomical mislocalization
Dataset bias
Domain shift between institutions
Unexpected pathology
Automation bias
Alert fatigue
Workflow interruption

AI may also recognize the MRI pattern without identifying the correct clinical context.

For example, an algorithm may detect tonsillar descent but fail to distinguish acquired brain sagging from congenital Chiari I morphology.

Similarly, detecting dural enhancement does not establish SIH because inflammatory, infectious, and neoplastic disorders may produce similar imaging findings.

The radiologist must therefore verify the complete clinical and imaging pattern.

AI Workflow in Radiology

For an enterprise imaging environment, a potential workflow could be conceptualized as:

DICOM → PACS → AI Orchestration → AI Analysis → PACS Visualization → Radiologist → RIS → EHR/EMR

For SIH, AI should ideally function as a second reader or prioritization tool rather than interrupting the radiologist with unnecessary alerts.

The value of such a system would depend on whether it improves recognition without creating excessive false positives or workflow burden.

The AI should not replace radiologist responsibility.

It should redistribute attention toward potentially important patterns.

Healthcare Workflow and Economic Perspective

SIH also illustrates why diagnostic accuracy can have downstream system implications.

A missed or delayed diagnosis may lead to:

Repeated clinical visits
Additional nonspecific imaging
Delayed spinal leak evaluation
Repeated procedures
Prolonged symptoms
More complex treatment
Additional hospitalization or specialist utilization

However, exact costs vary substantially by healthcare system, insurance coverage, imaging strategy, procedure type, and clinical course.

Therefore, the most defensible economic lesson is qualitative:

Better pattern recognition can potentially reduce unnecessary diagnostic iteration, but AI or imaging automation should not be assumed to produce financial savings without evidence of real-world workflow benefit.

Imaging Physics: Why Does the MRI Pattern Appear?

Understanding the imaging mechanism makes the pattern easier to recognize.

Reduced CSF volume decreases the normal buoyant support of the brain. Intracranial venous structures may enlarge as part of compensatory volume redistribution.

This can increase the visibility of venous structures and contribute to diffuse dural enhancement.

The pituitary gland may also appear enlarged because of venous congestion.

At the same time, reduced buoyancy can result in downward displacement of the brain, producing a characteristic sagging pattern.

Subdural fluid collections can develop as the relationship between the brain surface, bridging veins, and dura changes.

Thus, several seemingly unrelated MRI abnormalities can be connected by a single physiologic mechanism.

Practical Radiology Pearls

Orthostatic headache is a major clinical clue. Ask specifically how the headache behaved when it first began.
Think in patterns, not isolated signs. The combination of pachymeningeal enhancement, venous enlargement, subdural collections, pituitary enlargement, and brain sagging is more informative than any one feature.
A low-lying cerebellar tonsil is not automatically Chiari I malformation. Consider acquired brain sagging.
An enlarged pituitary gland is not automatically an adenoma. Evaluate it in the context of venous congestion and other SIH signs.
An atraumatic subdural hematoma can be a clue to CSF leakage.
Brain MRI may establish suspicion but may not localize the leak.
Whole-spine MRI can help guide subsequent leak-localization strategies.
CT myelography and DSM have complementary roles depending on the suspected leak mechanism.
Normal CSF opening pressure does not exclude SIH.
Treating the subdural hematoma alone may not solve the underlying problem if a CSF leak remains.

Common Diagnostic Pitfalls

Pitfall 1: Calling Every Low-Lying Tonsil “Chiari”

Tonsillar descent should be interpreted in the context of the entire intracranial configuration.

Pitfall 2: Calling Pituitary Enlargement a Tumor

Diffuse or relative pituitary enlargement can occur in the setting of venous congestion associated with SIH.

Pitfall 3: Stopping After Identifying a Subdural Hematoma

The hematoma may be a complication rather than the primary disease.

Pitfall 4: Assuming Dural Enhancement Is Specific

Pachymeningeal enhancement has a broad differential diagnosis.

Pitfall 5: Assuming a Negative Brain MRI Excludes SIH

Not every patient demonstrates the full classic imaging pattern.

Pitfall 6: Assuming Normal Opening Pressure Excludes SIH

CSF pressure measurement is not a definitive exclusion test.

Pitfall 7: Treating All Patients With the Same Imaging Strategy

Leak type, spinal findings, treatment response, and clinical status influence the next diagnostic step.

Frequently Asked Questions

What is the key MRI finding in spontaneous intracranial hypotension?

The most useful approach is to recognize a constellation of findings rather than one isolated sign. Diffuse pachymeningeal enhancement, subdural collections, venous sinus engorgement, pituitary enlargement, and brain sagging are major MRI manifestations of reduced CSF volume.

Can spontaneous intracranial hypotension cause a subdural hematoma?

Yes. Reduced CSF volume and downward brain displacement can place traction on bridging venous structures and contribute to subdural hemorrhage.

Can Chiari I malformation mimic spontaneous intracranial hypotension?

Yes. Both can demonstrate low-lying cerebellar tonsils. SIH is favored when tonsillar descent occurs with other signs such as diffuse pachymeningeal enhancement, venous enlargement, subdural collections, and broader brain sagging.

Does a normal CSF opening pressure rule out SIH?

No. A normal opening pressure does not by itself exclude spontaneous intracranial hypotension.

What imaging is used to locate a CSF leak?

Whole-spine MRI may provide an initial assessment. Depending on the findings and suspected leak type, CT myelography or digital subtraction myelography may be used for more precise localization.

What is an epidural blood patch?

An epidural blood patch involves injecting autologous blood into the epidural space to reduce or seal CSF leakage. It is an important treatment option for SIH, although some patients require additional targeted treatment.

Can AI detect spontaneous intracranial hypotension?

AI could potentially assist with recognition of individual imaging features or combinations of features associated with SIH. However, clinical validation is essential, and AI should be used as decision support rather than a replacement for radiologist interpretation.

What is the most important diagnostic mistake to avoid?

The major mistake is interpreting each MRI finding separately. The diagnostic value comes from integrating the clinical presentation with the overall pattern of reduced CSF volume.

Educational Quiz

Question 1

A woman in her early 40s has three weeks of orthostatic headache and dizziness. Brain MRI shows diffuse pachymeningeal enhancement, bilateral subdural collections, pituitary enlargement, low-lying cerebellar tonsils, and venous sinus enlargement. What is the most likely diagnosis?

A. Chiari I malformation
B. Spontaneous intracranial hypotension
C. Pituitary macroadenoma
D. Bacterial meningitis
E. Idiopathic intracranial hypertension

Answer: B. Spontaneous intracranial hypotension

The combination of orthostatic headache and multiple MRI signs of reduced CSF volume strongly supports SIH.

Question 2

Brain MRI strongly suggests SIH, but the intracranial study does not identify the actual CSF leak. What is the most appropriate next approach?

A. No further evaluation is necessary
B. Immediate craniotomy
C. Whole-spine MRI followed, when appropriate, by targeted myelographic evaluation
D. Exclude SIH if CSF opening pressure is normal
E. Pituitary biopsy

Answer: C. Whole-spine MRI followed, when appropriate, by targeted myelographic evaluation

The source of the CSF leak is often spinal and may require dedicated spinal imaging for localization.

Question 3

A patient with suspected SIH has a small subdural hematoma, no significant midline shift, no altered consciousness, and no focal neurologic deficit. What is the general management principle?

A. Every subdural hematoma requires immediate surgery
B. Treat only the hematoma
C. Monitor the hematoma while addressing the underlying CSF leak
D. CSF-leak treatment is contraindicated
E. No follow-up is necessary

Answer: C. Monitor the hematoma while addressing the underlying CSF leak

Management depends on hematoma size, mass effect, symptoms, and neurologic status. The underlying CSF leak should also be evaluated.

Key Takeaways

Spontaneous intracranial hypotension is best recognized through clinical-radiologic pattern integration.

The most important clues in this case are:

Orthostatic headache
Dizziness
Diffuse pachymeningeal enhancement
Bilateral subdural collections
Left subdural hematoma
Venous sinus enlargement
Pituitary enlargement
Brain sagging and low-lying cerebellar tonsils
Reduced CSF within the optic nerve sheath

The central imaging lesson is simple:

Do not interpret these findings independently. Interpret them as manifestations of reduced CSF volume.

Once SIH is suspected, the diagnostic pathway should move beyond the brain MRI toward assessment of the spinal CSF leak when clinically appropriate.

The ultimate goal is not simply to identify the MRI pattern. It is to connect the pattern to the underlying leak mechanism, appropriate localization strategy, treatment, and follow-up.

Continue Learning

References

Cheema S, et al. Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension. Journal of Neurology, Neurosurgery & Psychiatry. 2023;94(10):835–843. doi:10.1136/jnnp-2023-331166.
Headache Classification Committee of the International Headache Society. Headache attributed to spontaneous intracranial hypotension. The International Classification of Headache Disorders, 3rd edition (ICHD-3).
Amrhein TJ, Kranz PG. Spontaneous Intracranial Hypotension: Imaging in Diagnosis and Treatment. Radiologic Clinics of North America. 2019;57(2):439–451. doi:10.1016/j.rcl.2018.10.004.
Bond KM, et al. Spontaneous Intracranial Hypotension: Atypical Radiologic Appearances, Imaging Mimickers, and Clinical Look-Alikes. American Journal of Neuroradiology. 2020;41(8):1339–1347. doi:10.3174/ajnr.A6637.
Farb RI, et al. Spontaneous Intracranial Hypotension: A Systematic Imaging Approach for CSF Leak Localization and Management Based on MRI and Digital Subtraction Myelography. American Journal of Neuroradiology. 2019;40(4):745–753. doi:10.3174/ajnr.A6016.
Amrhein TJ, et al. Efficacy of Epidural Blood Patching or Surgery in Spontaneous Intracranial Hypotension: A Systematic Review and Evidence Map. American Journal of Neuroradiology. 2023;44(6):730–739. doi:10.3174/ajnr.A7880.
Callen AL, et al. Diagnosis and Treatment of Spontaneous Intracranial Hypotension. Neurology: Clinical Practice. 2024;14(3). doi:10.1212/CPJ.0000000000200290.
D'Antona K, et al. Clinical Presentation, Investigation Findings, and Treatment Outcomes of Spontaneous Intracranial Hypotension Syndrome: A Systematic Review and Meta-analysis. JAMA Neurology. 2021.
Govindappa SKG, et al. Spontaneous Intracranial Hypotension: A Review of Neuroimaging and Current Concepts. Indian Journal of Radiology and Imaging. 2024;34(1):128–138. doi:10.1055/s-0043-1774301.

Medical Disclaimer: This article is intended for medical education and does not replace professional diagnosis or treatment. Individual symptoms and imaging findings should be evaluated by an appropriately qualified healthcare professional.