22 - Low-pressure syndromes and cerebrospinal fluid leaks

Summary

Cerebrospinal fluid (CSF) leaks are increasingly considered an important cause of low-pressure headaches, particularly among younger patients. In addition to headaches, other symptoms have been reported in spontaneous intracranial hypotension including neck pain or stiffness, nausea, and emesis. Computed tomography (CT) scans may be a helpful initial diagnostic tool, for instance in the outpatient or emergency department setting, prior to more definitive imaging. While some findings of CSF leak in magnetic resonance imaging (MRI) can be variable, there are generally five characteristic imaging features most often associated with spontaneous intracranial hypotension: subdural fluid collections, enhancement of the meninges, and engorgement of venous structures, pituitary hyperemia, and sagging of the brain. Outcomes are good for the great majority of patients with spontaneous intracranial hypotension, but as some patients are refractory to any treatment, innovative but unproven therapies should be explored.