Spontaneous intracranial hypotension: From clinical suspicion to targeted treatment (based on presentations at the EAN Congress 2026)

Spontaneous intracranial hypotension (SIH) is a clinical syndrome most commonly caused by a spinal cerebrospinal fluid (CSF) leak through a dural defect or by a CSF-venous fistula. Although orthostatic headache is its classic manifestation, the clinical spectrum is broad, and normal lumbar puncture opening pressure or the absence of typical brain MRI findings does not exclude the diagnosis. Based on presentations delivered at the EAN Congress 2026, this review summarizes current approaches to the diagnosis and treatment of SIH. Particular attention is given to the role of brain and whole-spine MRI, assessment of spinal longitudinal epidural CSF collections, and targeted myelographic techniques used to localize the leak. Therapeutic options include nontargeted and targeted epidural blood patching, fibrin sealant occlusion, transvenous embolization, and surgical repair. The choice of treatment should be guided by the underlying leak mechanism, anatomical location, symptom duration, and response to previous interventions. Clinical improvement after an epidural blood patch does not necessarily indicate anatomical closure of the leak; persistent radiological signs warrant further investigation and referral to a specialized multidisciplinary center. Timely localization and definitive treatment may improve functional recovery and reduce the risk of long-term neurological complications.

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