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Intracranial hypotension from a spontaneous dural CSF leak is being diagnosed more frequently. Patients can present acutely with characteristic orthostatic headaches and with exertional or thunderclap headaches. Often the diagnosis is delayed and the headache disorder can evolve into a ‘chronic daily headache’ pattern. MR brain imaging can show classical features of intracranial hypotension such as subdural collections, pituitary hyperaemia, brain sagging, engorged venous sinuses with pachymeningeal enhancement with contrast being the hallmark finding. The MR brain scan is normal in up to 20% cases1 and a lumbar puncture or an MR scan of spine may be needed to confirm the diagnosis. CT or MR myelography can identify the site of CSF leak, though none is found in half of cases.2 For those with a fast CSF leak and large spinal CSF collection, dynamic CT and digital subtraction myelography may help.
Intracranial hypotension often resolves spontaneously and needs no further treatment. Strict bed …
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed. This paper was reviewed by Manjit Matharu, London, UK