CT Scan and MRI spinal imaging findings in
Spontaneous Intracranial Hypotension:
a case report
Sérgio Cardoso
Radiology Department - Hospitais Cuf
Lisbon, Portugal
XIX Symposium Neuroradiologicum
Spontaneous Intracranial Hypotension (SIH)

Syndrome of low cerebral spinal fluid (CSF) volume, secondary to CSF
leakeage into the epidural space (spinal meninges structural weakness)
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No previous history of surgery or lombar puncture;
Presence of trivial traumatic events in 1/3 of patients
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No epidemiological data available ( annual incidence 5/100.000 )

Affects young and middle age individuals; female/male ratio 2:1

Variable clinical presentation ; postural headache is the most common
manifestation
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Delay in diagnosis is very frequent
XIX Symposium Neuroradiologicum
Case Report


34 yo female

Suddenly onset of permanent severe, cervical pain one week before first
observation, with no relief or exacerbation features
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No other symptoms, as headache, fever, systemic

In physical examination the only finding was some degree of neck
stiffness, with otherwise normal physical and neurological examination

Laboratorial workout showed no significant abnormalities (normal CRP,
normal blood count, normal renal and hepatic function)
Previously healthy, with no relevant issues in her past medical history
XIX Symposium Neuroradiologicum
Cervical Spine CT Scan (03/06/2010)
Antero-lateral hyperdense epidural collection
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Brain MRI (03/06/2010)
No abnormal findings
XIX Symposium Neuroradiologicum
Spine MRI (03/06/2010)
EPIDURAL HEMATOMA ?
SPINAL AVM ?
Spine MRI
- spinal epidural collection
- dilated epidural veins
- enlargement of epidural venous plexus
- dural enhancement
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Spinal Angiography
 No spine AVM
 No signs of medular compression
 No clinical deterioration
→ conservative attitude
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Spine MRI (30/06/2010)
Typical neuroimaging features of SIH
- epidural fluid collections
- dural sac collapse- festooned appearence
- dural enhancement
- epidural venous plexus dilatation
- dilated epidural veins
--C1\C2 sign (absent)
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Dorsal and Lombar Spine MR (30/06/2010)
- collapse of dural sac
- dilatation of epidural venous plexus
XIX Symposium Neuroradiologicum
Brain MRI (30/06/2010)
Typical brain neuroimaging features of SIH
Subdural fluid collections
Enhancement of pachymeninges
Engorgemnt of venous structures
Pituitary hyperemia
Sagging of the brain
→ SEEPS
XIX Symposium Neuroradiologicum
CT Myelography (22/07/2010)
Persistent symptoms with conservative therapy (bed rest and hydratation) → CT myelography
The differential opacification of thecal sac and the ventral fluid collection → sign of
communication
The exact location of the communication could not be determined
XIX Symposium Neuroradiologicum
EVOLUTION
 Conservative measures uneffective (bed rest, oral hydration,
caffeine intake)
 Epidural blood patch (27/07/2010) → clinical improvement
 Spine and Brain MR (24/08/2010)
30/06/2010
24/08/2010
24/08/2010
03/06/2010
24/08/2010
XIX Symposium Neuroradiologicum
Take Home Messages
 Spontaneous intracranial hypotension (SIH) is not rare, but is
still underdiagnosed
 Clinical and imaging findings are widely variable
 CT Myelography is the study of choice to identify the CSF leak,
but is not always necessary to make the diagnosis
 The role of spinal imaging findings in SIH is not well
established, but awareness to abnormalities at this level can
lead to an earlier diagnosis

XIX Symposium Neuroradiologicum
XIX Symposium Neuroradiologicum