Spontaneous intracranial hypotension: A stepwise diagnostic and therapeutic workflow from a tertiary referral center

Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leakage leading to intracranial CSF hypovolemia and orthostatic headache. Diagnostic and therapeutic strategies remain heterogeneous across institutions. We report the outcomes of a structured stepwise diagnostic and therapeutic pathway applied in a tertiary referral center.

We performed a retrospective analysis of 106 consecutive patients treated for SIH between 2020 and 2025. All patients were managed according to a standardized escalation protocol including conservative treatment, non-targeted epidural blood patch (nt-EBP), advanced spinal leak localization with dynamic CT myelography, and etiology-directed surgical or endovascular treatment when indicated.

Initial nt-EBP resulted in complete clinical resolution in 64 patients. Forty-two patients with persistent or recurrent symptoms underwent advanced spinal imaging. Among them, 8 patients were diagnosed with lateral nerve root sleeve leaks and 4 with ventral dural tears related to osteophytes, all treated surgically, while 10 patients were diagnosed with CSF-venous fistulas and underwent transvenous embolization. All patients receiving etiology-directed surgical or endovascular treatment achieved complete clinical and radiological resolution. The remaining 20 patients without identifiable focal leak sites were managed with repeated nt-EBP, achieving partial clinical improvement and remaining under follow-up.

A structured stepwise management strategy improves diagnostic efficiency and therapeutic outcomes in SIH. Non-targeted epidural blood patch remains an effective first-line intervention. Early escalation to targeted spinal imaging in refractory cases enables etiology-directed surgical or endovascular treatment, which can provide definitive clinical and radiological cure in selected patients.