Spontaneous Intracranial Hypotension: A Tertiary Care Experience

Spontaneous intracranial hypotension (SIH) is a rare, often underdiagnosed cause of secondary headache resulting from spontaneous cerebrospinal fluid leakage. Indian data on its clinical profile and treatment outcomes remain limited. We aimed to describe the clinical, radiological, and treatment characteristics of patients with SIH at a tertiary neurology centre in South India and to compare outcomes between those treated with epidural blood patch (EBP) and conservative management.

This retrospective observational study included 33 patients fulfilling the International Classification of Headache Disorders - 3 (ICHD-3) diagnostic criteria for SIH between 2004 and 2024. Clinical features, magnetic resonance imaging (MRI) findings, treatment modalities, and outcomes were analyzed. Statistical comparisons were performed using Chi-square or t tests, with P < 0.05 considered significant.

Of the 33 patients (73% female; mean age, 42 ± 11 years), orthostatic headache was present in 91%. Pachymeningeal enhancement was the most common MRI finding (90%), followed by pituitary engorgement (59%) and spinal epidural fluid collections (52%). Twenty patients (61%) received EBP, and thirteen (39%) were managed conservatively. EBP led to significantly higher rates of headache resolution at discharge (80% vs. 31%, P = 0.005), although long-term outcomes at 3 months were comparable (75% vs. 62%, P = 0.5). Procedure-related complications were mild and transient.

This study represents the largest Indian SIH series to date, highlighting the predominance of orthostatic headache and pachymeningeal enhancement. EBP offers rapid symptomatic relief and remains the preferred initial therapy. Early recognition and standardized imaging protocols are vital for improved outcomes.