Imaging recommendation · Neuro · Head & Neck

Orthostatic headache, suspected spontaneous intracranial hypotension

Q: What's the alternative imaging for orthostatic headache, suspected spontaneous intracranial hypotension when leak source not identified on mri?

CT — CT myelogram or dynamic myelography (iv contrast).

Q: What's the alternative imaging for orthostatic headache, suspected spontaneous intracranial hypotension when suspected csf-venous fistula?

CT — Decubitus CT myelography or digital subtraction myelography (iv contrast).

Recommended: MRI Brain with contrast (SEEPS findings) + Spine MRI for CSF leak source is the preferred imaging study for orthostatic headache, suspected spontaneous intracranial hypotension. CSF leak from spinal dural defect.

Recommended study

MRI Brain with contrast (SEEPS findings) + Spine MRI for CSF leak source

MRI IV contrast Preferred Neuro · Head & Neck OutpatientAcute inpatient Reviewed 2026-05

CSF leak from spinal dural defect. Headache worsens upright, improves recumbent.

If the default doesn't apply

Leak source not identified on MRI

CT CT myelogram or dynamic myelography IV contrast

Suspected CSF-venous fistula

CT Decubitus CT myelography or digital subtraction myelography IV contrast

Watch-outs

Subdural hematomas / brain sag

Severe SIH can cause SDH and brain herniation — emergent epidural blood patch consideration.

Pearls

SEEPS findings: Subdural collections, Enhancement of pachymeninges, Engorged venous structures, Pituitary enlargement, Sagging of brain.
Epidural blood patch first-line treatment after imaging confirms leak.
CSF-venous fistula is an underrecognized cause; needs decubitus / dynamic imaging.