In a patient with possible intracranial hypotension, headache, dizziness, a history of non‑Hodgkin lymphoma, and prior back injections, does the MRI brain show any evidence of dural compromise or cerebrospinal fluid leak?

MRI Brain Interpretation: No Evidence of Dural Compromise

This MRI brain shows no imaging features of intracranial hypotension or dural compromise from the back injections. The absence of pachymeningeal enhancement, normal venous sinuses, preserved midline structures, and lack of subdural collections all argue strongly against active CSF leak 1.

Key Imaging Findings Analysis

Why This MRI Does NOT Support Intracranial Hypotension

The ACR Appropriateness Criteria (2024) define specific qualitative and quantitative brain MRI signs that indicate intracranial hypotension 1:

Major signs (absent in this patient):

• No pachymeningeal enhancement - This is one of the most specific findings for CSF leak and carries 2 points on the Bern scoring system 1, 2
• No venous sinus engorgement - Flow voids are preserved and normal 1
• Normal suprasellar cistern - Midline structures are within normal limits (effacement ≤4.0 mm would suggest hypotension) 2

Minor signs (absent in this patient):

• No subdural fluid collections - Explicitly stated as no significant finding 1, 2
• Normal prepontine cistern - Would be effaced (≤5.0 mm) in intracranial hypotension 2
• No midbrain descent or tonsillar descent - Midline structures normal 1

Bern Score Assessment

Using the validated Bern scoring system, this patient scores 0 points (out of 9 possible), placing them in the low probability category for spinal CSF leak 2. A score of ≥5 indicates high probability, 3-4 intermediate probability, and ≤2 low probability 2.

Clinical Context Integration

History of Back Injections

The spine—not the brain—is where CSF leaks originate 1. The ACR guidelines explicitly state that "the spine has been shown to represent the anatomical source of most symptomatic CSF leaks and venous fistulas, such that the imaging investigation of leak source should be directed primarily toward the spine and not intracranially" 1.

However, if dural puncture occurred, brain MRI would typically show characteristic findings within 72 hours to weeks 1. The complete absence of these findings makes clinically significant dural compromise highly unlikely 1.

The White Matter Hyperintensities

The mild nonspecific T2 FLAIR hyperintensities are unrelated to intracranial hypotension or dural compromise 1. These are correctly attributed in the radiology report to:

• Migraines (relevant given headache history)
• Prior infection/trauma
• Early chronic small vessel disease

These findings do not represent CSF leak sequelae 1.

Next Steps Based on Clinical Suspicion

If Intracranial Hypotension Remains Suspected Clinically

Despite the negative brain MRI, if orthostatic headache persists:

Proceed directly to spinal imaging 1:

• MRI complete spine without and with IV contrast is the recommended next step 1
• Look for direct signs: epidural fluid collections, CSF-venous fistula 1
• Look for indirect signs: dilated epidural venous plexus, spinal subdural collections, dural enhancement 1

Important caveat: CSF pressure can be normal in patients with SIH, and absence of low CSF pressure should not exclude the condition 1. However, brain MRI findings typically correlate with presence of spinal leak 2.

If Symptoms Persist After Negative Workup

Consider alternative diagnoses 1:

• Positional orthostatic tachycardia syndrome (POTS)
• Cervicogenic headaches
• Migraines (supported by white matter changes)
• New daily persistent headache syndromes

Critical Clinical Pitfall

Do not assume that a history of back injections automatically means CSF leak 1. Post-dural puncture headache typically:

• Occurs within 72 hours of the procedure 1
• Resolves within 14 days in most cases 3
• Would show brain MRI findings if chronic 3

Recent research (2025) demonstrates that patients with chronic post-dural puncture headache actually have LOW Bern scores (median 2.0), similar to this patient's score of 0 3. This suggests either resolution of the leak or an alternative diagnosis 3.

Regarding Non-Hodgkin Lymphoma History

The lymphoma history is not relevant to this MRI interpretation for intracranial hypotension 4. There is no abnormal intracranial enhancement to suggest leptomeningeal disease or other CNS involvement.

Bottom line: This brain MRI provides no evidence that the dura was compromised by the back injections. If clinical suspicion for CSF leak remains high despite this negative brain imaging, proceed directly to dedicated spinal MRI imaging rather than repeating brain imaging 1.