Patients with SIH have distinct MRI and sometimes radioisotope cisternographic abnormalities and generally respond favorably to conservative management.

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Spontaneous intracranial hypotension can be effectively cured by lumbar autologous EBP in Trendelenburg position pre-medicated with acetazolamide.

Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, low CSF pressure and diffuse pachymeningeal enhancement on brain magnetic resonance imaging (MRI) (1, 2). Atypical cases with normal CSF pressure (3), normal cranial MRI (4) and without postural headache (5) have also been reported. SIH generally results from spinal spontaneous CSF leakage, sometimes associated with underlying connective tissue disorders (6, 7). Treatment is usually conservative. Sometimes an autologous epidural blood patch (AEBP) at the site of CSF leakage may be necessary (8).We describe a patient with a spontaneous cervical CSF leak treated with autologous lumbar epidural blood patch (far from the site of the CSF leak). Case reportA man aged 45 years had sudden, severe, gravative fronto-occipital orthostatic headache with nausea, tinnitus and, after 7 days, diplopia. Neurological examination showed left VI cranial nerve paresis; routine blood tests and brain computed tomography were normal. Brain MRI showed diffuse pachymeningeal enhancement. Gadolinium spinal MRI showed a CSF epidural collection from C2 to D3 level ( Fig. 1). After 1 month of bed rest and hydration symptoms were still present. The patient was treated with lumbar AEBP (25 ml) at L2-L3 level. The blood was mixed with 0.05 ml of gadolinium. Epidural blood injection was stopped when the patient experienced lumbar pain and nausea. During and after injection of blood, he remained in the Trendelemburg position (TP) of approximately 30 ° for about 2 h. Spinal postpatch MRI showed gadolinium mixed with blood in the epidural space from the lumbar to cervical level (Fig. 2). He subsequently remained in TP for 22 h. Twenty-four hours after AEBP, orthostatic headache disappeared. After 1 week tinnitus and diplopia also diseappeared. At 6-month follow-up he was in good health and his brain and spinal MRI were normal. DiscussionAutologous epidural blood patch is considered the treatment of choice in those patients who have failed the initial non-invasive treatments in SIH. Relief of headache is often almost instantaneous and this is probably related to the acute compression of the thecal sac resulting in an increase of CSF pressure. AEBP given at level of the leak is generally considered more effective than given at a distant site. Some authors have demonstrated with postlumbar blood patch MRI that the mean spread of the blood patch in the epidural space was 4.6 ± 0.9 intervertebral levels. Most of the blood spread in the cephalad direction (9). This cephalad spread correlates with the findings in a prior study, wich described, using technetium-labelled red cells, a mean spread of the blood patch of six spinal segments upwards and three segments caudally (10). In this case we have demonstrated that AEBP, even though injected at the level of the lumbar spine (i.e. far from the site of CSF leak), may move upward, reaching the cervical segments. This is possibly favoured by TP. So a rapid coagulation response at the dural hole level stops CSF leakage forming a...