Resolution of pachymeningeal enhancement is a radiographic marker for effective treatment of spontaneous intracranial hypotension: patient series

BACKGROUND: Spontaneous intracranial hypotension (SIH) may result in positional headaches, tinnitus, vestibular symptoms, and cognitive dysfunction. Pachymeningeal enhancement may be seen on contrast-enhancing imaging. Notably, the time course of pachymeningeal enhancement resolution has previously been shown to resolve within 17 hours of surgical repair. The authors sought to determine whether radiographic stigmata of SIH could be used as a marker for effective treatment. OBSERVATIONS: A retrospective review of 14 patients who underwent open surgical management for SIH was conducted. Clinical notes and pre-and postoperative images were used to determine resolution of pachymeningeal enhancement. All patients experienced resolution of preoperative positional headaches on initial follow-up, with a median of 12 days following surgery. Diffuse pachymeningeal enhancement was found on preoperative MRI brain in all patients, with postoperative imaging showing resolution of pachymeningeal enhancement, with a median of 2 days postsurgery. LESSONS: Diffuse pachymeningeal enhancement is a reliable marker for resolution SIH and often predates clinical resolution. Therefore, the authors propose that assessing for this characteristic with contrasted-brain MRI may assist in the posttreatment evaluation of patients with SIH. https://thejns.org/doi/10.3171/CASE25819.