1. CT Scan and MRI spinal imaging findings in Spontaneous Intracranial Hypotension: a case report Sérgio Cardoso Radiology Department - Hospitais Cuf Lisbon, Portugal

2. Spontaneous Intracranial Hypotension (SIH)
Syndrome of low cerebral spinal fluid (CSF) volume, secondary to CSF leakeage into the epidural space (spinal meninges structural weakness)
No previous history of surgery or lombar puncture; Presence of trivial traumatic events in 1/3 of patients
No epidemiological data available ( annual incidence 5/ )
Affects young and middle age individuals; female/male ratio 2:1
Variable clinical presentation ; postural headache is the most common manifestation
Delay in diagnosis is very frequent

3. Case Report
34 yo female
Previously healthy, with no relevant issues in her past medical history
Suddenly onset of permanent severe, cervical pain one week before first observation, with no relief or exacerbation features
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)

4. Cervical Spine CT Scan (03/06/2010)
Antero-lateral hyperdense epidural collection

5. Brain MRI (03/06/2010)
No abnormal findings

6. Spine MRI (03/06/2010) EPIDURAL HEMATOMA ? SPINAL AVM ?
Spine MRI spinal epidural collection
- dilated epidural veins
- enlargement of epidural venous plexus
- dural enhancement
Normal brain MRI errounesly dismissed SIH diagnosis; with the spine findings at this time this hypothesis should have been considered

7. Spinal Angiography No spine AVM No signs of medular compression
No clinical deterioration
→ conservative attitude

8. 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)

9. Dorsal and Lombar Spine MR (30/06/2010)
- collapse of dural sac
dilatation of epidural venous plexus

10. 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

11. 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

12. 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)
03/06/2010
24/08/2010
30/06/2010
24/08/2010
24/08/2010

13. 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