What are the treatment measures for intracranial hypotension?

Treatment Measures for Intracranial Hypotension

The primary treatment for intracranial hypotension should focus on management of the underlying cerebrospinal fluid (CSF) leak, combined with appropriate symptomatic relief. 1

Initial Conservative Management (First 2 Weeks)

• Conservative measures should be tried for up to two weeks and include:
  • Bed rest to reduce CSF pressure gradient and minimize leakage 2
  • Adequate hydration to support CSF production 2
  • Appropriate pain relief with acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs) 1
  • Caffeine intake (e.g., tea consumption) may help alleviate symptoms by increasing CSF production 3
  • Opioids may be required for severe pain but should be avoided for long-term management 1

Epidural Blood Patch (EBP)

• Non-targeted high-volume EBP should be performed as early as possible if symptoms persist despite conservative management 1
• The procedure involves:
  • Injection of 15-20 mL of autologous blood with strict aseptic technique 4
  • Blood should be injected slowly and incrementally 4
  • Consider repeat EBP if symptoms persist after initial treatment 1

Advanced Diagnostic and Treatment Algorithm

For MRI-Positive Patients:

1. Perform MRI brain with contrast and MRI whole spine to identify CSF leak location 1
2. If MRI shows signs of spontaneous intracranial hypotension (SIH) or meningeal diverticula:
   • Arrange high-volume non-targeted EBP 1
   • If symptoms persist, refer to specialist neuroscience center 1
   • At specialist center, management should be discussed by a multidisciplinary team 1

For MRI-Negative Patients:

1. If clinical suspicion remains high despite negative initial imaging:
   • Consider dynamic CT or dynamic digital subtraction myelography 1
   • These specialized imaging techniques can help identify CSF leaks not visible on standard MRI 1

Targeted Interventions for Identified Leaks

• When a specific leak site is identified through advanced imaging:
  • Targeted patching with blood or fibrin glue 1
  • Surgical repair for persistent leaks, especially for meningeal diverticula 5
  • Transvenous embolization for CSF-venous fistulas 1

Management of Complications and Symptoms

• For rebound headache after treatment:

  • Patients should be informed about this possibility before procedures 1
  • Evaluate for secondary intracranial hypertension 1
  • Consider acetazolamide to lower CSF production if symptoms are severe 4

• For non-headache symptoms:

  • Provide antiemetics for nausea and vomiting 1
  • Encourage adequate hydration 1
  • Consider orthostatic rehabilitation for patients who have been bedbound 1

Important Considerations and Pitfalls

• Avoid medications that potentially lower CSF pressure (topiramate, indomethacin) or reduce blood pressure (candesartan, beta blockers) as they may exacerbate symptoms 1
• Monitor for medication overuse headache in patients using frequent analgesics 1
• Be aware that some patients may respond to fludrocortisone treatment when conservative measures fail 6
• Recognize that rebound headaches are usually self-limited and can be managed conservatively 1

Follow-up Recommendations

• Early review within 24-48 hours after any intervention 4
• If rebound headache is severe or worsening continues after 1-2 weeks, further clinical review is indicated 1
• Regular assessment of headache severity, time able to spend upright, and associated symptoms 4