The common denominator of spontaneous intracranial
hypotension (SIH), postsurgical cerebral
spinal fluid (CSF) leaks, and postpuncture headache
(PPH) is a decrease in CSF volume. The
typical presentation is orthostatic headaches, but
atypical headaches can be difficult to diagnose
and challenging to treat. Management is based
on clinical suspicion and characterization of the
headache, followed by imaging (noninvasive or
invasive). Treatment ranges from conservative
to different modalities of epidural blood patches,
fibrin glue injections, or surgical exploration and
repair.
We report 5 cases with great variation in clinical
and radiological presentations. Two cases of
SIH involved difficult diagnosis and treatment, 2
others featured postsurgical high-flow CSF leaks,
and one case presented with a low-flow CSF
leak that needed closer evaluation in relation to
hardware manipulation.
In all cases, recommendations for diagnosis and
management of intracranial hypotension were followed,
even though in 3 cases the mechanism of
trauma was not related to spontaneous hypotension.
All cases of headache were resolved.
The actual recommendations for SIH are very
effective for PPH and postsurgical CSF leaks.
With this case series, we illustrate how anatomical
and clinical considerations are paramount in
choosing appropriate imaging modalities and
clinical management.
Key words: CSF leak, epidural blood patch,
intracranial hypotension, postural headaches,
subdural hematomas