Abstract
Spontaneous intracranial hypotension is a condition characterized by low CSF volume secondary to leakage through a dural defect with no identifiable cause. Patients classically present with orthostatic headaches, but this symptom is not specific to spontaneous intracranial hypotension, and initial misdiagnosis is common. The most prominent features of spontaneous intracranial hypotension on intracranial MR imaging include "brain sag" and diffuse pachymeningeal enhancement, but these characteristics can be seen in several other conditions. Understanding the clinical and imaging features of spontaneous intracranial hypotension and its mimickers will lead to more prompt and accurate diagnoses. Here we discuss conditions that mimic the radiologic and clinical presentation of spontaneous intracranial hypotension as well as other disorders that CSF leaks can imitate.
Highlights
Distinguishing FeaturesCerebellar tonsils inferiorly pointed Midbrain descent absent Usually unilateral Focal or diffuse May have leptomeningeal involvement, skull base prominence, hypertrophic pachymeningitis Usually systemic symptoms and involvement of other organs
Sagittal MIP (B) and coronal (E) images from a contrast-enhanced CT venogram confirm a long-segment acute, expansile thrombus as a filling defect within the superior sagittal sinus, as well as multiple bilateral left-greaterthan-right superior cortical veins. While he was being treated for sinus thrombosis, he reported that his headaches were orthostatic in nature
Spontaneous intracranial hypotension is caused by various types of defects in the spinal dura and subsequent CSF extravasation
Summary
Cerebellar tonsils inferiorly pointed Midbrain descent absent Usually unilateral Focal or diffuse May have leptomeningeal involvement, skull base prominence, hypertrophic pachymeningitis Usually systemic symptoms and involvement of other organs. Normal cerebellar tonsil shape Midbrain descent present Usually bilateral Brain sag and focal dural enhancement Diffuse, non-nodular dural thickening and enhancement. Fall in systolic (20 mm Hg) and/or diastolic (10 mm Hg) blood pressure on standing from a seated or supine position. Headache with neck pain that worsens with cervical motion, relieved with medication
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