OBJECTIVES To analyze and compare differences between epidemiological and clinical aspects, as well as radiologic findings and treatment, in a series of adult patients with traumatic intracranial hypotension (TIH) and spontaneous intracranial hypotension (SIH) treated at our institution in order to identify predictors of recurrence. BACKGROUND Cerebrospinal fluid hypotension headache (CSF-HH) is often caused by orthostasis and relieved by recumbency. Etiology can be either traumatic or spontaneous. Indirect signs of CSF hypotension are often observed on brain MRI. The most common therapeutic approach is conservative management and, when necessary, the use of an epidural blood patch. METHODS Medical history and brain MRI of adult patients consulting our institution with a diagnosis of CSF-HH between January 2010 and March 2019, were retrospectively reviewed. Clinical criteria as per the International Classification of Headache Disorders, 3rd edition, were applied. Presence of typical MRI findings were assessed by two experienced neuroradiologists, previously informed of patients' clinical characteristics. Patients were divided into two different groups, namely: Group A: Spontaneous Intracranial Hypotension (SIH) and Group B: Traumatic Intracranial Hypotension (TIH). Recurrence was defined as return of symptoms after one month of remission. In order to find predictors of recurrent intracranial hypotension the patients were divided into three groups: Recurrent Orthostatic headache (ROH); (33 cases; 25%); Non-Recurrent Orthostatic headache (NROH) (84; 61%) and Patients missing follow-up (20; 15%). The latter were excluded from the regression analysis. RESULTS 137 patients with CSF-HH were identified: 80 traumatic (54 women, age 33.8 ± 10.4 years) and 57 spontaneous (31 women, age 43.9 ± 15.2 years). Median follow-up was 35 months (range: 8 months-9 years). Compared with TIH, patients with SIH showed lower frequency of orthostatic headache and higher frequency of aural fullness. Also, in patients with SIH, brain MRI showed a higher frequency of pachymeningeal enhancement, ventricular collapse, cisternal obliteration, posterior fossa crowding, brainstem distortion, and a more likely presence of subdural collections. Patients with SIH required an epidural blood patch treatment more often, showed higher recurrence rates, and were more prone to develop subdural hematomas. RECURRENCE As more days elapsed between headache onset and clinical consultation, the presence of spontaneous intracranial hypotension, tinnitus, and thoraco-lumbo-sacral pain were all more common in patients with recurrence. Findings on brain MRI suggesting higher recurrence rates in patients included: ventricular collapse, brainstem distortion, and posterior fossa crowding. Patients treated with invasive therapy (epidural blood patch) presented a higher recurrence rate. In the multivariate regression analysis, the only independent predictor of recurrence after adjusting for age, sex and traumatic vs spontaneous cause of IH, was brainstem distortion diagnosed on MRI (OR 5.13, 95% CI: 1.2-21.7; p = 0.026). CONCLUSIONS SIH and TIH can no longer be likened, since there is considerable variability in clinical presentation, imaging findings, response to treatment and recurrence rates. Anatomical abnormalities underlying SIH leaks are often complex and not simply a disruption of normal structures as encountered in TIH, which could explain why treatment success is poor and recurrence rates remain high.

中文翻译：

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外伤性与自发性脑脊液低血压性头痛：我们在 137 例病例中的经验

目的 分析和比较在我们机构接受治疗的一系列创伤性颅内低血压 (TIH) 和自发性颅内低血压 (SIH) 成年患者的流行病学和临床方面以及放射学发现和治疗之间的差异，以确定复发。背景脑脊液低血压头痛（CSF-HH）常由直立引起，卧床可缓解。病因可以是创伤性的，也可以是自发性的。脑脊液低血压的间接征象经常在脑部 MRI 上观察到。最常见的治疗方法是保守治疗，必要时使用硬膜外血片。方法 2010 年 1 月至 2019 年 3 月期间就诊于我们机构并诊断为 CSF-HH 的成年患者的病史和脑部 MRI，进行了回顾性审查。应用了国际头痛疾病分类第 3 版的临床标准。典型 MRI 结果的存在由两位经验丰富的神经放射科医师评估，他们事先了解了患者的临床特征。患者被分为两个不同的组，即： A 组：自发性颅内低血压 (SIH) 和 B 组：创伤性颅内低血压 (TIH)。复发定义为缓解 1 个月后症状复发。为了找到复发性颅内低血压的预测因素，将患者分为三组：复发性直立性头痛（ROH）；（33 例；25%）；非复发性直立性头痛 (NROH) (84; 61%) 和患者错过随访 (20; 15%)。后者被排除在回归分析之外。结果 确定了 137 名 CSF-HH 患者：80 名外伤性（54 名女性，年龄 33.8 ± 10.4 岁）和 57 名自发性（31 名女性，年龄 43.9 ± 15.2 岁）。中位随访时间为 35 个月（范围：8 个月至 9 年）。与 TIH 相比，SIH 患者的直立性头痛频率较低，而耳闷胀的频率较高。此外，在 SIH 患者中，脑部 MRI 显示硬脑膜增强、心室塌陷、脑池闭塞、后颅窝拥挤、脑干变形的频率更高，并且更可能存在硬膜下积液。SIH 患者需要更频繁的硬膜外血液补片治疗，显示出更高的复发率，并且更容易发生硬膜下血肿。复发 随着头痛发作和临床咨询之间的时间越来越长，自发性颅内低血压、耳鸣和胸腰骶疼痛在复发患者中更为常见。脑部 MRI 的发现表明患者的复发率较高，包括：心室塌陷、脑干扭曲和后颅窝拥挤。接受侵入性治疗（硬膜外血贴）治疗的患者复发率较高。在多元回归分析中，调整年龄、性别和外伤性与自发性 IH 原因后复发的唯一独立预测因素是 MRI 诊断的脑干畸变（OR 5.13，95% CI：1.2-21.7；p = 0.026）。结论 SIH 和 TIH 不能再相提并论，因为在临床表现、影像学发现、对治疗的反应和复发率方面存在相当大的差异。