Citations 1
Abstract 252: Increasing Incidence of Spontaneous Intracranial Hypotension and Cerebrospinal Fluid‐Venous Fistulas: Role of Enhanced Clinical Awareness in the Advanced Myelography Era
Hajj, Georges, Kadirvel, Ramanathan , Kallmes, David F. , Brinjikji, Waleed , Hajj, G. El, Ognard, Julien , Bayraktar, E.
Stroke: Vascular and Interventional Neurology | December 2, 2025 | Volume: 5 | Issue: S1 | Pages: No page available
Introduction Spontaneous intracranial hypotension (SIH) has been underdiagnosed, primarily due to limited clinical recognition and diagnostic capabilities. Recent improvements in diagnostic awareness and the implementation of advanced imaging techniques, notably targeted myelography and photon‐counting computed tomography (PCCT), have improved detection of cerebrospinal fluid‐venous fistulas (CSFVFs). We provide an updated SIH incidence within a defined U.S. County and quantify the proportional contribution of CSFVFs in this evolving diagnostic context. Methods We performed a retrospective, population‑based cohort study of adults evaluated for SIH from January 2019 through August 2025 at a quaternary referral center. Standard evaluation included brain MRI, whole‑spine MRI screening for spontaneous spinal CSF leaks (SLEC), and targeted myelography (lateral‑decubitus digital subtraction or dynamic CT/PCCT when available). Incident SIH was defined as the first imaging‑confirmed leak per patient. Incidence per 100,000 adult person‑years used adult population denominators with exact Poisson 95% CIs. Results We identified 33 incident SIH cases; 22/33 (66.7%) were CSFVF. Overall SIH incidence was 4.02 (95% CI 2.77‐5.65) per 100,000 person‑years; CSFVF‑specific incidence was 2.68 (95% CI 1.68‐4.06), 2.35 in women (95% CI 1.25‐4.02) and 1.50 in men (95% CI 0.65‐2.96). Significant upward trends were observed in annual incidence rates for SIH (Incidence Rate Ratio [IRR]: 1.23, 95% CI: 1.02‐1.48, p = 0.027) and specifically for CSFVFs (IRR: 1.29, 95% CI: 1.03‐1.63, p = 0.029). The symptom duration before diagnosis had a median of 4 months and appears to be shortening over time: 7 months in 2019‐2021 versus 4 months in 2022‐2025, consistent with faster recognition and targeted imaging. Conclusion The incidence of SIH, particularly due to CSFVFs, has increased significantly, likely attributable to improved clinical recognition and advanced imaging techniques rather than a true epidemiological shift. This highlights an urgent clinical message: maintain a high index of suspicion, image accordingly, and treat promptly. image image