Recommendations for the Management of Spontaneous Intracranial Hypotension With Spinal Longitudinal Epidural CSF Collection
14 affiliations
- 1Graduate School of Translational Medicine, Seoul National University College of Medicine, South Korea
- 2Department of Anesthesiology, Stanford University, CA
- 3Yellow Rose Headache and Neuro-Ophthalmology Dallas, TX
- 4Department of Radiology, Duke University, Durham, NC
- 5Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea
- 6Headache and Facial Pain Group, University College London Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, United Kingdom
- 7Department of Neurology, Emory School of Medicine, Atlanta, GA
- 8Danish Headache Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet-Glostrup, Denmark
- 9Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- 10Hospital Israelita Albert Einstein, Hospital das Clinicas FMUSP, São Paulo, Brazil
- 11Department of Neurology, Taipei Veterans General Hospital, Taiwan
- 12College of Medicine, National Yang Ming Chiao Tung University, Taiwan
- 13Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
- 14Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, South Korea .
Abstract
Background and Objectives: Spontaneous intracranial hypotension (SIH) results from spinal CSF leakage. Epidural blood patch (EBP) is an important first-line treatment. However, pre-EBP, intra-EBP, and post-EBP practice varies widely owing to limited consensus guidance. We aimed to develop expert consensus statements to support clinical decision-making in SIH management, including peri-EBP practices, focusing on patients with spinal longitudinal epidural CSF collection (SLEC) before definitive leak type classification.
Methods: An international multidisciplinary Delphi process was conducted between January 2024 and July 2025, involving experts in neurology, neurosurgery, radiology, and anesthesiology. Consensus was defined a priori as ≥70% agreement for strong agreement, 60%–69% for partial agreement, and <60% for no consensus, based on a 5-point Likert scale in round 3. Responses were collected anonymously using an online survey platform, with summarized feedback from the previous round provided between rounds.
Results: Fourteen experts were invited, with 10, 9, and 9 participants in rounds 1, 2, and 3, respectively. Before EBP, bed rest was recommended for recent-onset SIH with severe orthostatic headache (88.9%); other conservative methods such as abdominal binder and hydration were considered not mandatory (90%). Semitargeted EBP was recommended as initial management for patients with extradural CSF collections (70%). Dynamic CT myelography was preferred for localization (70%). Post-EBP care was variable, particularly in bed rest duration, with most recommendations (70%) exceeding 12 hours. Definitions of clinical remission (80%) and radiologic remission (90%) were established. Radiologic follow-up after clinical remission was recommended (78%). No consensus was reached on follow-up strategies for persistent symptoms, although “doing nothing” was not recommended. No consensus was reached for persistent extradural CSF despite clinical remission, requiring an individualized approach. Light activity after EBP was recommended within a few days (70%). No consensus was reached on the optimal number of EBPs before invasive leak localization or surgical intervention.
Discussion: This Delphi study outlines expert recommendations and uncertainties for SIH management, including peri-EBP practices. This study incorporated the initial management strategy for patients in whom leak-type classification was incomplete. However, the treatment section primarily focused on the SLEC-positive setting and presumed ventral dural tears; lateral dural tears and CSF-venous fistulas warrant future consensus development.
Related
- Spontaneous Intracranial Hypotension with Bilateral Subdural Haematomas and Posterior Cerebral Artery Infarcts with Delayed Epidural Blood Patch Response: A Case Report
- Spontaneous Intracranial Hypotension Presenting With Acute Orthostatic Headache: A Case Report
- Age-related differences in clinical manifestations, neuroimaging features, and treatment of spontaneous intracranial hypotension: a retrospective cohort study.
- Rates of Retreatment after Transvenous Embolization of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension
- Evaluation of the C1-C2 False Localizing Sign in Spontaneous Intracranial Hypotension: Prevalence and Clinical Insights
BibTeX
@article{choi2026recommendations,
title = {{Recommendations for the Management of Spontaneous Intracranial Hypotension With Spinal Longitudinal Epidural CSF Collection}},
author = {Soyoun Choi and Ian Carroll and Deborah I. Friedman and Peter G. Kranz and Eugene Lee and Manjit Matharu and Simy Parikh and Henrik W. Schytz and Marcio Nattan Portes Souza and Yen-Feng Wang and Hsiangkuo Yuan and Mi Ji Lee},
journal = {Neurology},
year = {2026},
month = oct,
doi = {10.1212/wnl.0000000000218638},
url = {https://doi.org/10.1212/wnl.0000000000218638},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Recommendations for the Management of Spontaneous Intracranial Hypotension With Spinal Longitudinal Epidural CSF Collection
AU - Soyoun Choi
AU - Ian Carroll
AU - Deborah I. Friedman
AU - Peter G. Kranz
AU - Eugene Lee
AU - Manjit Matharu
AU - Simy Parikh
AU - Henrik W. Schytz
AU - Marcio Nattan Portes Souza
AU - Yen-Feng Wang
AU - Hsiangkuo Yuan
AU - Mi Ji Lee
PY - 2026
DA - 2026/10/16
JO - Neurology
DO - 10.1212/wnl.0000000000218638
UR - https://doi.org/10.1212/wnl.0000000000218638
AB - Background and Objectives: Spontaneous intracranial hypotension (SIH) results from spinal CSF leakage. Epidural blood patch (EBP) is an important first-line treatment. However, pre-EBP, intra-EBP, and post-EBP practice varies widely owing to limited consensus guidance. We aimed to develop expert consensus statements to support clinical decision-making in SIH management, including peri-EBP practices, focusing on patients with spinal longitudinal epidural CSF collection (SLEC) before definitive leak type classification. Methods: An international multidisciplinary Delphi process was conducted between January 2024 and July 2025, involving experts in neurology, neurosurgery, radiology, and anesthesiology. Consensus was defined a priori as ≥70% agreement for strong agreement, 60%–69% for partial agreement, and <60% for no consensus, based on a 5-point Likert scale in round 3. Responses were collected anonymously using an online survey platform, with summarized feedback from the previous round provided between rounds. Results: Fourteen experts were invited, with 10, 9, and 9 participants in rounds 1, 2, and 3, respectively. Before EBP, bed rest was recommended for recent-onset SIH with severe orthostatic headache (88.9%); other conservative methods such as abdominal binder and hydration were considered not mandatory (90%). Semitargeted EBP was recommended as initial management for patients with extradural CSF collections (70%). Dynamic CT myelography was preferred for localization (70%). Post-EBP care was variable, particularly in bed rest duration, with most recommendations (70%) exceeding 12 hours. Definitions of clinical remission (80%) and radiologic remission (90%) were established. Radiologic follow-up after clinical remission was recommended (78%). No consensus was reached on follow-up strategies for persistent symptoms, although “doing nothing” was not recommended. No consensus was reached for persistent extradural CSF despite clinical remission, requiring an individualized approach. Light activity after EBP was recommended within a few days (70%). No consensus was reached on the optimal number of EBPs before invasive leak localization or surgical intervention. Discussion: This Delphi study outlines expert recommendations and uncertainties for SIH management, including peri-EBP practices. This study incorporated the initial management strategy for patients in whom leak-type classification was incomplete. However, the treatment section primarily focused on the SLEC-positive setting and presumed ventral dural tears; lateral dural tears and CSF-venous fistulas warrant future consensus development.
SN - 0028-3878
SN - 1526-632X
ER -