Outcome after surgical treatment of cerebrospinal fluid leaks in spontaneous intracranial hypotension-a matter of time

J Neurol. 2022 Mar;269(3):1439-1446. doi: 10.1007/s00415-021-10710-7. Epub 2021 Jul 18.


Objective: Spinal cerebrospinal fluid (CSF) leaks cause spontaneous intracranial hypotension (SIH). Microsurgery can sufficiently seal spinal CSF leaks. Yet, some patients suffer from residual symptoms. Aim of the study was to assess predictors for favorable outcome after surgical treatment of SIH.

Methods: We included consecutive patients with SIH treated surgically from January 2013 to May 2020. Subjects were surveyed by a questionnaire. Primary outcome was resolution of symptoms as rated by the patient. Secondary outcome was postoperative headache intensity on the numeric rating scale (NRS). Association between variables and outcome was assessed using univariate and multivariate regression. A cut-off value for continuous variables was calculated by a ROC analysis.

Results: Sixty-nine out of 86 patients (80.2%) returned the questionnaire and were analyzed. Mean age was 46.7 years and 68.1% were female. A significant association with the primary and secondary outcome was found only for preoperative symptom duration (p = 0.001 and p < 0.001), whereby a shorter symptom duration was associated with a better outcome. Symptom duration remained a significant predictor in a multivariate model (p = 0.013). Neither sex, age, type of pathology, lumbar opening pressure, nor initial presentation were associated with the primary outcome. ROC analysis yielded treatment within 12 weeks as a cut-off for better outcome.

Conclusion: Shorter duration of preoperative symptoms is the most powerful predictor of favorable outcome after surgical treatment of SIH. While an initial attempt of conservative treatment is justified, we advocate early definitive treatment within 12 weeks in case of persisting symptoms.

Keywords: Low ICP syndrome; Orthostatic headache; Spinal cerebrospinal fluid leak; Spontaneous intracranial hypotension.

MeSH terms

  • Cerebrospinal Fluid Leak / diagnostic imaging
  • Cerebrospinal Fluid Leak / etiology
  • Cerebrospinal Fluid Leak / surgery
  • Female
  • Headache / etiology
  • Humans
  • Intracranial Hypotension* / diagnostic imaging
  • Intracranial Hypotension* / etiology
  • Intracranial Hypotension* / surgery
  • Magnetic Resonance Imaging
  • Middle Aged