Our multidisciplinary Spontaneous Intracranial Hypotension (SIH) Program provides coordinated evaluation, advanced imaging to locate leaks, and targeted treatments — from epidural blood patching to endovascular and surgical repair.

The U-M Health Neurointerventional Radiology (NIR) team has been established in the practice of minimally invasive treatment of neurological pathology in adult and pediatric populations for more than two decades. The team provides unparalleled expertise and the most advanced diagnosis and treatment methods for patients with spontaneous intracranial hypotension (SIH). In conjunction with our colleagues in Neurology, Neurodiagnostic Radiology, Neurosurgery, Pain Medicine, Neuro-ophthalmology, and Physical Therapy, the condition is diagnosed and consensus treatment recommendations are provided.

Through close collaboration, the multi-disciplinary team at U-M Health strives to provide individualized care for each patient while helping to educate and guide patients through the journey of diagnosis and treatment.

Physicians and providers are also actively involved in research collaborations to further the understanding of SIH and advance the treatment of CSF leaks.

To make an appointment, call the Neurointerventional Radiology Adult Clinic at (734) 936-4500 Option 151.

Fax: (734) 232-1577

Common symptoms of SIH include:

• Orthostatic (postural) headache — worse when upright, improves on lying down (the hallmark symptom).
• Neck/back pain, nausea, dizziness, tinnitus, photophobia, visual disturbance.

Less common symptoms include:

• Cognitive changes, gait disturbance, muffled hearing, tinnitus, visual disturbances, or subdural hematoma in severe/untreated cases.

When to seek care:

• Individuals should seek immediate evaluation for severe neurologic change, persistent orthostatic headache, or new neurological deficits.

Patients will undergo a complete history & physical examination with a focus on a neurologic assessment.

Important imaging and tests include:

• Brain MRI with contrast (gadolinium) — often shows diffuse (smooth) pachymeningeal enhancement, pituitary enlargement, downward brainstem sagging, venous distention, and small subdural collections. These findings strongly suggest SIH.
• Spine MRI — may show epidural CSF collections, meningeal diverticula, or other indirect signs.
• Myelography (CT or digital subtraction myelography) is performed in provocative positions including prone and lateral decubitus (on your side) — used to localize a spinal leak (targeted imaging is preferred when planning definitive repair).
• Radionuclide cisternography
• Lumbar opening pressure may be low but can be normal in some patients, so normal opening pressure does not exclude SIH.

Conservative measures include bed rest, oral hydration, caffeine, abdominal binders for short term symptom relief. Many patients improve with these measures initially.

Interventional/surgical repair

• Epidural blood patch (EBP) — the front-line procedural treatment for many SIH patients:

  • Non-targeted (blind) EBP — provides symptomatic relief in many patients.
  • Targeted EBP (delivered at or near the radiographically identified leak) has higher reported success when leak location is known. Repeat or targeted EBPs are common.
  • Multi-level Epidural via Guide-catheter Autologous (MEGA) Blood Patch — Large  volume blood patch performed via single epidural access for deposition of blood/fibrin  glue from cervical to lumbar regions in the setting of cryptogenic spinal CSF leak.

• CT/fluoroscopic-guided fibrin glue patching

• Microsurgical dural repair for focal spinal dural tears

• Endovascular treatment of CSF-venous fistula including transvenous embolization

• Microsurgical ligation of CSF-venous fistula