The cause of idiopathic intracranial hypotension (IH) is most often a spinal CSF leak. A history of trauma, even unremarkable, can be determined in approximately 30% of patients suffering from IH but in the majority of patients the cause of CSF leakage remains unidentified [1]. Most cases of IH respond well to conservative measures such as bed rest, oral hydration, and administration of caffeine or corticosteroids. In patients with persistent symptoms of orthostatic headache, stiff neck, tinnitus or nausea and vomiting, an epidural blood patch (EBP) is an established treatment option, which is most effective if the CSF leak had been exactly localized. CSF leak localization is technically demanding and often not possible by conventional imaging. A 42-year old female patient developed severe (8/10 on the visual analogue scale), occipitally accentuated orthostatic headache, tinnitus and slight neck stiffness two days following chiropractic manipulation of the thoracic spine. Over the following days, the headache worsened while standing or sitting, and improved within minutes after lying down. Neurological examination was otherwise unremarkable. Doppler and duplex sonography largely excluded vertebral artery dissection. CSF opening pressure was 4 cmH2O, CSF analysis revealed moderately increased protein (934 mg/l) but normal values for lactate, glucose and cell count. Subarachnoid haemorrhage could be excluded. These findings were strongly suggestive of IH, and accordingly a CSF leak was suspected. Cranial MRI did not show characteristic signs of IH, and subdural haemorrhage was excluded. Sagittal and axial T2-weighted spine MRI with spectral fat saturation was performed with a 3.0 T MR scanner. Images of the thoracic spine showed alterations consistent with left-sided root sheath cysts at levels Th10/11 and Th12/L1 but no signs of CSF leakage. Thereafter, off-label gadolinium-enhanced myelography was performed to demonstrate CSF leakage. Informed consent from the patient was obtained. Lumbar puncture was performed at level L4/L5, and 5 ml of CSF were drained. Afterwards, 0.3 ml of gadubutrol diluted with 5 ml of saline were instilled intrathecally. Sagittal and axial T1-weighted MRI with spectral fat saturation 10–15 min post injection revealed an extension of enhanced CSF around the left nerve roots at levels Th3/4 and Th10/11 (Fig. 1a and b). Conservative treatment (bed rest, oral hydration, and administration of analgesics and caffeine) had failed. Approximately 50 days after clinical onset and 2 days after performing MR-myelography the patient underwent an EBP with 15 ml of autologous blood mixed with 3 ml of iodinated contrast agent, injected at level Th10/11 (Fig. 1c and d). The epidural blood extended (Fig. 1d) up to the level Th3/4. After the procedure, the orthostatic headache rapidly improved, and two days later, the patient could be discharged. It is known that CSF leakage can occur after even minor ‘‘trauma’’, such as coughing, lifting, pushing, sport activities, or falls [2, 3]. Only very few cases have been published on patients suffering from CSF leaks as a consequence of chiropractic manipulations of the spine [3, 4]. M. Wagner (&) U. Ziemann Department of Neurology, Goethe University, Schleusenweg 2-16, 60528 Frankfurt, Germany e-mail: marlies.wagner@kgu.de