PO-29 | Spontaneous intracranial hypotension: a clinical and radiological observational study

F. Verna, D. Mascarella, V. Favoni, G. Pierangeli, L. Cirillo, S. Cevoli | IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia DIBINEM, Alma Mater Studiorum Bologna, Italy

Background: Spontaneous intracranial hypotension (SIH) is a condition characterized by orthostatic headache and low cerebrospinal fluid (CSF) pressure in the absence of clear causes. Diagnosis relies on clinical features and radiological findings, while treatment ranges from conservative management to invasive procedures such as epidural blood patch (EBP) or embolization. Recurrence occurs in approximately 10% of cases. This study aims to identify clinical, radiological, and therapeutic predictors of treatment response and recurrence to develop a standardized diagnostic and therapeutic algorithm.

Methods: We present findings from a retrospective analysis of a monocentric cohort of patients diagnosed with SIH according to ICHD-3 criteria and referred to IRCCS-ISNB. Demographic, clinical, and neuroimaging data were collected and analyzed.

Results: A total of 36 patients were included (M:F = 4:5), with a mean age at onset of 50.6 years. Connective tissue disorders were suspected in 16% of patients. Orthostatic headache was present in all cases (100%), followed by cervical pain (23%) and tinnitus (3%). Imaging findings included a pontomesencephalic angle <50° in 82.6% (mean 33.78°) and pituitary gland enlargement >6.5 mm in 78.3% (mean 8.98 mm). Among recurrent patients, pituitary enlargement (100% vs. 66.7%), suprasellar cistern obliteration (83.3% vs. 55.6%), and venous distension (100% vs. 50%) were more frequent compared to non-recurrent cases. Advanced spinal imaging (CT myelography) identified CSF leaks in 100% of cases. Targeted epidural blood patch resulted in symptom resolution. The mean interval between symptom onset and treatment was 90 days, with a shorter duration in non-recurrent patients (69 vs. 103 days).

Conclusion: The data suggest a possible role of connective tissue abnormalities in the pathogenesis of SIH. Orthostatic headache was universally present, while other clinical signs and radiological findings varied between recurrent and non-recurrent groups. CT myelography effectively localized CSF leaks and guided treatment. Early diagnosis and targeted therapy are associated with improved outcomes and lower recurrence risk, underscoring the importance of larger, prospective studies to validate predictive factors and refine management strategies.