Spontaneous Intracranial Hypotension – A Rare but Important Cause of Secondary Headache.

Spontaneous intracranial hypotension is an uncommon cause of headache. Diagnosis requires high index of suspicion. It can be easily missed if not considered in differentials. It can be missed on plain MRI if intra venous contrast is not given. We report Nine cases of spontaneous intracranial hypotension who came with acute to subacute presentation of postural headache. Four patients were treated conservatively with bed rest and IV uids. These patients were followed up clinically and radiologically. Follow up clinical and MRI showed complete resolution of symptoms in four conservatively treated patients. Two patients were treated surgically. One patient required bilateral craniotomy in view of worsening of subdural haematoma. One patient was treated with bilateral craniotomy and epidural blood patch. Three patients were treated with epidural blood patch alone. All patients except one responded to treatment on follow up. ConclusionSpontaneous intracranial hypotension requires clinical suspicion and a contrast MRI for diagnosis. Conservative trial should be given before proceeding for epidural blood patch unless there is worsening of symptoms or signs. Duration of observation for conservative treatment before proceeding for epidural blood patch is individualized. In select subset bilateral craniotomy for subdural haematoma is required along with epidural blood patch.