Balancing the System: Occult Spinal CSF Leak Leading to Spontaneous Intracranial Hypotension

Abstract Spontaneous intracranial hypotension (SIH) is an underdiagnosed cause of headache and neurological dysfunction, often missed when classical orthostatic features are absent. We present a 43-year-old woman with chronic, non-specific neurological symptoms ultimately found to have an occult spinal cerebrospinal fluid (CSF) leak. Brain MRI demonstrated diffuse pachymeningeal enhancement, and CT myelography confirmed extraspinal CSF egress. The patient experienced complete resolution following targeted epidural blood patching. This case highlights the diagnostic challenges of SIH and emphasises the importance of maintaining suspicion and using appropriate imaging, even when routine studies appear normal.