“Don’t Miss the Right Timing — A Case of Spontaneous Intracranial Hypotension Successfully Treated with Surgery”

1) Introduction — Why Should You Read This?

“When I sit up, it feels like my head suddenly drops, but it gets better when I lie down.”
When I hear things like this from patients, I feel a sense of urgency.
Many people dismiss this as a simple headache, endure it for weeks, and then end up needing surgery due to severe cerebrospinal fluid (CSF) leakage.

Spontaneous intracranial hypotension (SIH) presents with various symptoms, and diagnosis is often delayed.
But when surgery is performed at the right time, the outcomes can be surprisingly positive.

In this post, written from the perspective of our neurosurgical clinic in the Gangseo area, we’ll discuss:
→ What causes SIH and how it's diagnosed
→ Principles of surgical treatment
→ A real-life case that improved significantly with surgery
→ Why timing is critical and what to watch out for

You may even find that the symptoms described here sound familiar to your own experience.

Source: None

2) What Is Spontaneous Intracranial Hypotension? — Understanding the Pathophysiology and Common Misconceptions

SIH is a condition where the pressure inside the skull drops abnormally.
In most cases, this happens because CSF leaks from somewhere in the spinal or cranial dura.
CSF normally cushions and protects the brain and spinal cord. When its volume decreases, the brain may sag downward due to the loss of buoyancy.

This leads to headaches and sometimes autonomic symptoms like tinnitus.
The most common symptom is orthostatic headache—worse when upright, better when lying down.
However, others may experience dizziness, blurred vision, or even trouble concentrating, which can lead to misdiagnosis as migraine or tension headache.

Source: D’Antona et al., JAMA Neurology, 2021

3) Diagnostic Process — Finding the Leak and Imaging Techniques

Accurate diagnosis requires imaging.
Brain MRI often shows diffuse meningeal enhancement or brain sagging.
However, in many cases, these images are not enough to pinpoint the exact leakage site.

That’s when more specialized tests come in—spinal MRI, CT myelography, or radionuclide cisternography.
Newer tools like Digital Subtraction Myelography can detect even tiny leaks.
Identifying the correct leak site is crucial, especially when there are multiple leaks.

Source: Hee-Chang Ko et al., Korean Headache Society Journal, 2009

4) Treatment Strategy — From Conservative Care to Surgery

If symptoms are mild or the leak location is unclear, we start with conservative treatment:
strict bed rest, IV fluids, caffeine, and sometimes steroids.

If symptoms persist, we move on to an epidural blood patch (EBP)—injecting the patient’s own blood into the epidural space to seal the leak.

If EBP fails or symptoms remain despite repeated attempts, surgical intervention becomes necessary.
Surgery involves directly locating and sealing the leaking site or placing a patch to reinforce the dura.

Source: D’Antona et al., JAMA Neurology, 2021 / Sobczyk et al., 2022

5) Case Example — Surgical Success at Seoul Jeil Neurosurgery

A 45-year-old female patient had been suffering from orthostatic headaches for over 6 weeks.
Her pain worsened when sitting up and improved when lying down.

Brain MRI showed subtle brain sagging and mild meningeal enhancement.
CT myelography identified a suspected leak at the T6 level of the thoracic spine.

An EBP was attempted but failed to relieve the symptoms.
We proceeded with microscopic surgery to suture the dural tear and apply a reinforcing patch.

After surgery, her orthostatic headaches improved significantly.
At a 3-month follow-up MRI, no leak was found.

Source: Häni et al., Springer, 2021

6) Timing and Prognosis — Why Early Intervention Matters

If left untreated for too long, SIH may become chronic, and outcomes worsen.
Research shows that patients who undergo surgery within 12 weeks of symptom onset have significantly higher recovery rates.

Delays may lead to dural thickening, subdural hematomas, or persistent brain sagging, all of which complicate treatment.
So early diagnosis and timely surgical decisions are key to successful recovery.

Source: Häni et al., Springer, 2021 / Continuum AAN, 2022

7) Our Clinical Practice at Gangseo — Seoul Jeil Neurosurgery Principles

At our clinic, we follow structured protocols to improve diagnostic accuracy and treatment outcomes:

1. Stepwise imaging protocol — symptoms → brain/spine MRI → myelography if needed

2. Limit conservative and non-surgical methods to 6–8 weeks

3. Consider surgery if no improvement after that window

4. Continuous post-op follow-up and rehabilitation

5. Tailored patient education and shared decision-making

We emphasize early intervention and work closely with patients to help them return to normal daily life.

Source: Internal clinical protocol / Sobczyk et al., 2022

8) Key Points and Misconceptions to Avoid

• SIH can exist even without orthostatic headache
• MRI may appear normal—advanced imaging might be required
• Multiple leak sites are possible
• Surgery isn’t for everyone, but timing is critical

Source: Continuum AAN, 2022 / D’Antona et al., 2021

Conclusion

SIH is often missed or misdiagnosed.
But with early and accurate diagnosis, followed by the appropriate treatment—even surgery when necessary—patients can recover fully.

At Seoul Jeil Neurosurgery in Gangseo, we are committed to delivering precise diagnosis and evidence-based treatment strategies to restore our patients’ quality of life.