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Original research
Natural history of spontaneous intracranial hypotension: a clinical and imaging study
  1. James Williams1,
  2. Waleed Brinjikji2,
  3. Jeremy K Cutsforth-Gregory3
  1. 1 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 Department of Radiology & Neurological Surgery, Mayo Clinic, Rochester, MN, USA
  3. 3 Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr James Williams, Mayo Clinic, Rochester, Minnesota, USA; Williams.james4{at}


Background Although spontaneous intracranial hypotension (SIH) is well studied, there are few studies of the clinical and imaging history of SIH without interventional treatments. For example, what is the natural history of those who are untreated or treated only with conservative measures?

Objective To conduct a retrospective study examining changes in imaging findings for patients with SIH without interventional treatments and to study associations between imaging findings and clinical symptoms.

Methods Included patients had a clinical diagnosis of SIH, were seen at Mayo Clinic between 1999 and 2021, had a brain MRI scan indicating SIH (Bern score), and had a brain MRI scan 6 or more months later without intervening leak-related interventional treatment. Bern scores were assigned for the first and last MRI scans prior to treatment. Patients were also grouped into three qualitative categories: overall improvement of symptoms, stable symptoms, or worsened symptoms based on patient report during the clinical visit at the time of the follow-up brain MRI scan.

Results Among 46 patients with untreated SIH, the Bern score improved over time in 11 (24%), was stable in 30 (65%), and worsened in 5 (11%). Two patients (4.3%) showed complete resolution of all abnormalities by the Bern scoring criteria. Symptoms improved in 7 (15%), were stable in 29 (63%), and worsened in 10 (22%).

Conclusions In patients with brain MRI evidence of SIH, almost 25% demonstrated radiographic improvement, and 15% reported clinical improvement, during at least 6 months of observation or conservative treatment. Most had stable, persistent MRI abnormalities and symptoms when SIH was untreated.

  • MRI
  • Intracranial Pressure
  • Intervention

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors This study was designed, directed, and coordinated by JW, WB and JKC-G. JW was the lead data collector and author of the manuscript. Each author contributed significantly to concept design, data analysis, and revisions of the manuscript. JW acts as the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.