CSF volume provocation maneuvers during lumbar puncture as a possible predictive tool for diagnosing spontaneous intracranial hypotension

Clin Neurol Neurosurg. 2019 Nov;186:105552. doi: 10.1016/j.clineuro.2019.105552. Epub 2019 Oct 7.


Objectives: Spontaneous intracranial hypotension (SIH) is a pathologic state of low CSF volume caused by a CSF to venous fistula or CSF leak. It is diagnosed based on symptoms, imaging, and CSF pressure but is often a diagnostic challenge because no single test is highly sensitive. Physician-induced changes in CSF volume may result in changes in patient symptoms, as has been shown with idiopathic intracranial hypertension (IIH). The purpose of this study is to determine the sensitivity of CSF volume provocation maneuvers in the diagnosis of SIH.

Patients and methods: We reviewed consecutive patients that underwent lumbar puncture from January 2015 to January 2017. Patients were included if they met ICHD3 criteria for SIH and CSF volume provocation maneuvers were performed. Cases were considered concordant if there was improvement of symptoms with addition of CSF.

Results: 1084 patients underwent 2250 CT-guided lumbar punctures from January 2015 to January 2017. 92 patients with SIH were identified and 62 of these patients underwent CSF volume provocation maneuvers. 58% (36/62) had concordant lumbar puncture encounters with symptom improvement upon addition of artificial CSF.

Conclusion: CSF volume provocation maneuvers demonstrate 58% sensitivity for identifying patients with SIH, better than those reported for CSF opening pressure and myelography. A positive symptomatic response to CSF volume provocation maneuvers was independent of the other objective tests used for SIH and may aid in the often-challenging diagnostic workup of these patients. Future prospective case-controlled studies are needed.

Keywords: Cerebrospinal fluid; Headache; Spontaneous intracranial hypotension.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Cerebrospinal Fluid Pressure / physiology*
  • Female
  • Humans
  • Intracranial Hypotension / diagnostic imaging*
  • Intracranial Hypotension / surgery
  • Magnetic Resonance Imaging / methods
  • Magnetic Resonance Imaging / trends
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Retrospective Studies
  • Spinal Puncture / methods*
  • Spinal Puncture / trends
  • Tomography, X-Ray Computed / methods
  • Tomography, X-Ray Computed / trends
  • Young Adult