Spontaneous Intracranial Hypotension (SIH) aka CSF Leak
Spontaneous intracranial hypotension (SIH) is a cause of headache and a variety of other neurologic manifestations. A causative CSF leak at the level of the spine can be detected in most patients, and several types of leaks have been identified. Epidural blood patching is successful in reduc- ing or eliminating symptoms in most patients and can be used without localization of the leak. For cases that do not respond to blood patching, specialized spinal imaging is indicated to local- ize the site of the CSF leak, and several surgical and nonsurgical treatment options have become available, depending on the type of leaks.
Zítek H, Stratilová M, Radovnický T, Sejkorová A, Klzo LH, Sameš M. Spontaneous intracranial hypotension. Ces a Slov Neurol a Neurochir. 2022;85(1):18–23.
Symptoms:
Nausea and Vomiting: Due to increased intracranial pressure or related to headaches.
Neck Pain or Stiffness: Discomfort in the neck region.
Tinnitus: Ringing or buzzing sounds in the ears.
Other Symptoms:
Visual Disturbances: Blurred vision or changes in vision.
Hearing Changes: Hearing loss or sensations of fullness in the ears.
Cognitive Changes: Difficulty concentrating or confusion.
Clear Fluid Draining: Leakage of clear, watery fluid from the nose or ears, particularly if there has been recent head trauma.
There is good evidence to suggest that a generalized connective tissue disorder plays a crucial role in the development of spontaneous spinal CSF leaks. BOX 1. Download Connective Tissue Disorders Review of Systems document
Although a postural headache is the clinical hallmark of spontaneous intracranial hypotension, it is well known that the posture-related component often, but not invariably, becomes less promi- nent or even disappears over time when the underlying spinal CSF leak re- mains untreated. A 48 hour flat test can be helpful to determine the relationship of posture to the headache. Download 48 Hour Flat Test.
Finally, some patients deny having any headache, usually when other symp- toms of spontaneous intracranial hy- potension predominate the clinical picture.
Because of the wide variety of head-ache patterns, magnetic resonance im- aging (MRI) should be considered for all patients with unexplained head- ache to evaluate for spontaneous intra- cranial hypotension. A differential di- agnosis ofheadache due to spontaneous intracranial hypotension. Includes new daily persistent headache, subarachnoid hemorrhage, carotid/vertebral artery dissection, cerebral venous sinus thrombosis, benign intracranial hypertension, post-traumatic headache, meningitis.
Schievink WI. Spontaneous Spinal Cerebrospinal Fluid and ongoing investigations in this area. Jama. 2006;295(19):2286–96.
Causes:
- Trauma: Head injuries, including fractures of the skull or spine, can create openings for CSF to escape.
- Surgery: Surgical procedures involving the brain or spine may inadvertently cause a CSF leak.
- Spontaneous Leak: Often occurs without any apparent cause, especially in individuals with conditions such as spontaneous intracranial hypotension or connective tissue disorders.
- Infections: Certain infections, such as meningitis, can damage the membranes surrounding the brain and spinal cord, leading to leaks.
- Invasive Procedures: Lumbar punctures (spinal taps) or epidural injections can sometimes lead to a CSF leak.
Treatments:
There are several effective ways to alleviate the pain, including a variety of treatments beyond just medication. Treatment options for CSF Leak include:
Epidural blood patch at or near the level of the leak
Epidural fibrin glue injection
Neurosurgical Referral
Click and Download CSF Test Here
Download and take this at home CSF Test and then bring in the results to Dr. Fishman.
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