Unusual neuroimaging findings in spontaneous intracranial hypotension

The most common neuroimaging manifestations of patients suffering from spontaneous intracranial hypotension (SIH) include subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, sagging of the brainstem, and cerebellar hemosiderosis. However, infrequently patients may present with separate neuroradiological findings which could be easily mistaken for other pathology.

We describe patients who presented with unique neuroimaging findings who were eventually found to have a spinal CSF leak or venous fistula. Relevant clinical history and neuroradiology findings are presented, and a relevant review of the literature is provided.

We present six patients with a proven CSF leak or fistula who presented with dural venous sinus thrombosis, compressive ischemic injury, spinal hemosiderosis, subarachnoid hemorrhage, pial vascular engorgement, calvarial hyperostosis, and spinal dural calcifications.

Radiologists should be familiar with atypical neuroimaging manifestations of SIH in order to avoid misdiagnosis and guide the clinical trajectory of the patient towards accurate diagnosis and eventual cure.