Symptoms of Cerebrospinal Fluid Leak
The hallmark symptom of CSF leak is orthostatic (positional) headache that worsens when upright and improves when lying down, occurring in 83% of patients, though 14% present with non-postural headache patterns. 1
Primary Clinical Features
Headache Characteristics
- Orthostatic headache is the defining feature, characterized by worsening when standing or sitting and improvement when supine in 83% of cases 1
- Non-postural headache occurs in 14% of patients, making diagnosis more challenging 1
- Neck pain or stiffness (nuchal rigidity) is present in 35% of cases 1
Associated Neurological Symptoms
- Nausea and/or vomiting occur in 28-77% of patients 1
- Photophobia (light sensitivity) is commonly reported 1
- Auditory disturbances, including tinnitus and hearing changes, occur in 11% of patients 1
- Visual disturbances, including diplopia (double vision), occur in 3-11% of cases 1
Secondary Symptoms
Less Common Presentations
- Disequilibrium or vertigo occurs in 8% of patients 1
- Sensory changes are present in 11% of cases 1
- Altered mental status occurs in 8% of patients 1
- Plegia/paresis (weakness or paralysis) may occur in 3% of cases 1
- Dizziness and diminished hearing are additional symptoms 2
- Cranial nerve palsies may be found on neurological examination 2
Critical Warning Signs Requiring Urgent Evaluation
Any sudden change in headache pattern warrants immediate assessment for cerebral venous thrombosis, which occurs in approximately 2% of spontaneous intracranial hypotension cases but can be life-threatening. 1, 3
Red Flags for Complications
- Sudden change in headache pattern may indicate cerebral venous thrombosis 1, 3
- New neurological deficits, including motor weakness, sensory disturbances, or cranial nerve palsies, warrant urgent evaluation 1
- Seizures or altered consciousness may indicate intracranial hemorrhage or venous thrombosis complications, occurring in 8% of cases 1
Additional Concerning Features
- Severe back or leg pain 3
- Lower limb motor weakness or sensory disturbance 3
- Urinary or fecal incontinence 3
- Fever 3
Clinical Pitfalls to Avoid
- Do not dismiss non-orthostatic headache patterns, as 14% of CSF leak patients present without classic positional features 1
- Recognize that patients can be asymptomatic, making diagnosis challenging in some cases 4
- Consider CSF leak in patients with chronic subdural hematoma, as this can be a presenting feature in the absence of typical orthostatic headache 5
- Be aware of pseudo-Chiari malformation on imaging, which can result from downward displacement of cerebellar tonsils and pons due to low CSF pressure 2