Neuroradiolog y/Head and Neck Imaging • Original Research

Kranz et al.
Imaging Signs of SIH

Neuroradiology/Head and Neck Imaging

Original Research

Time-Dependent Changes
in Dural Enhancement
Associated With Spontaneous
Intracranial Hypotension
Peter G. Kranz1 OBJECTIVE. The objective of our study was to determine whether the presence of in-
Timothy J. Amrhein dividual imaging signs of spontaneous intracranial hypotension (SIH) is correlated with in-
Kingshuk Roy Choudhury creasing duration of headache symptoms. Of particular interest is the relationship of symp-
Teerath Peter Tanpitukpongse tom duration to dural enhancement because it is the most commonly identified imaging sign
Linda Gray in patients with SIH.
MATERIALS AND METHODS. Eighty-nine patients with SIH who underwent pre-
Kranz PG, Amrhein TJ, Choudhury KR, treatment brain MRI and total-spine CT myelography and whose medical record included
American Journal of Roentgenology 2016.207:1283-1287.

­Tanpitukpongse TP, Gray L data on the duration of clinical symptoms were included in this cross-sectional retrospective
study. Brain imaging was reviewed for the presence of dural enhancement, brain sagging, and
the “venous distention” sign. CT myelograms were assessed for CSF leak. If present, a leak
was subcategorized as a high-flow or low-flow leak. Differences in headache duration be-
tween subjects with and those without individual imaging signs were compared.
RESULTS. Subjects without dural enhancement on brain MRI had a longer average du-
ration of symptoms than those with dural enhancement present (average symptom duration:
45.3 ± 59.0 [SD] vs 15.1 ± 33.0 weeks, respectively; p = 0.002). No difference in symptom du-
ration was observed between subjects whose MRI studies showed and those whose MRI stud-
ies did not show brain sagging (p = 0.10) or the venous distention sign (p = 0.21). The pres-
ence of a CSF leak on CT myelography was not associated with symptom duration (p = 0.56)
except in the subgroup of patients with low-flow leaks.
CONCLUSION. Increasing symptom duration in SIH is associated with decreased
prevalence of abnormal dural enhancement on brain MRI. Because dural enhancement is
considered a hallmark imaging feature of this condition, its absence may exacerbate the prob-
lem of underdiagnosis in chronic cases of SIH.

pontaneous intracranial hypo- tempting to establish the diagnosis of SIH be-

S tension (SIH) is an increasingly

Keywords: brain MRI, CSF leak, CT myelography,
spontaneous intracranial hypotension
DOI:10.2214/AJR.16.16381
Received March 14, 2016; accepted after revision
May 28, 2016.
1
All authors: Department of Radiology, Duke University
Medical Center, Box 3808, Durham, NC 27710. Address
correspondence to P. G. Kranz (peter.kranz@duke.edu).
AJR 2016; 207:1283–1287
0361–803X/16/2076–1283
© American Roentgen Ray Society
recognized cause of chronic
headache. Diagnosis often de-
pends on the detection of characteristic im-
aging abnormalities on brain MRI, the most
common of which is diffuse, smooth dural
contrast enhancement on contrast-enhanced
imaging [1, 2]. This enhancement is thought
to represent a physiologic response to CSF
volume loss whereby intracranial vascular
structures (including those within the dura)
are forced to dilate to compensate for the to-
tal intracranial volume lost as a result of spi-
nal CSF leakage [3].
Although highly characteristic of SIH and
explainable by the physiologic principles ac-
companying CSF leakage, dural enhancement
is not present in approximately 20% of patients
with SIH [4]. This fact is problematic when at-
cause other imaging markers of SIH—such as
MRI evidence of brain sagging, MRI evidence
of the “venous distention” sign, and CT myelo-
graphic evidence of CSF leak—are found less
commonly than dural enhancement and are
therefore less reliable indicators of the disease
[4]. The absence of dural enhancement may
therefore increase the likelihood of misdiag-
nosis, an already common problem in patients
with SIH [5]. Identifying which patients are
more likely to show variability in the presence
of dural enhancement is therefore important.
One potential clue to the variability in du-
ral enhancement may lie with the mounting
evidence suggesting that SIH is not a static
process but, rather, is one in which the un-
derlying physiology changes with time. For
example, CSF pressure, which is often found
to be abnormally low in patients with the dis-

AJR:207, December 2016 1283

 Kranz et al.

A B C
Fig. 1—57-year-old man with positional headache. Brain imaging reveals common imaging abnormalities associated with spontaneous intracranial hypotension.
A, Abnormal diffuse, smooth dural enhancement (arrowheads) is seen on axial contrast-enhanced T1-weighted image.
B, MR image shows “venous distention” sign (arrow), whereby borders of dominant transverse venous sinus are convex, rather than normal concave configuration, and
result in rounded appearance of sinus.
C, MR image shows brain sagging with downward sloping of third ventricular floor, narrowing of suprasellar cistern, and descent of mammillary bodies (arrow) to level of
dorsum sella.
American Journal of Roentgenology 2016.207:1283-1287.

ease, has been shown to rise with time even
if CSF leakage is ongoing [6]. Similarly,
clinical symptoms often change with time as
well, and many patients experience a reduc-
tion in the stereotypical orthostatic compo-
nent of their headaches, which may evolve
into nonorthostatic headaches [7]. Whether
the imaging features of SIH, including dural
enhancement, also change with time remains
an unexplored question.
The primary purpose of this investigation
was to determine whether dural enhance-
ment on MRI in patients with SIH is corre-
lated with an increasing duration of clinical
headache symptoms. We also sought to de-
termine whether other imaging signs of SIH
such as MRI evidence of brain sagging, MRI
evidence of the venous distention sign, and
CT myelographic evidence of CSF leak vary
with symptom duration.
Materials and Methods
This investigation is a retrospective cross-sec-
tional study of patients with SIH. Subjects were
identified from a database search of patients with
SIH treated at our institution between January
2006 and October 2014 that was performed as part
of a separate investigation examining the relation-
ship between the imaging signs of SIH and CSF
pressure [4]. This study was approved by our local
institutional review board and is compliant with
HIPAA regulations.
Subjects
A total of 99 subjects who met the crite-
ria for SIH according to the criteria proposed
by Schievink et al. [8] and whose pretreatment
brain MRI studies were available in our institu-
tion’s PACS were identified. All subjects under-
went CT myelography as part of their workup [9].
The duration of each patient’s clinical symptoms
was determined from the clinical history record-
ed in the electronic medical record; assessment of
the duration of headache symptoms, including a
specific starting date if possible, is part of the his-
tory obtained from patients at our institution us-
ing a standardized pretreatment questionnaire.
Ten of these 99 patients (10%) were excluded be-
cause information about the duration of their clin-
ical symptoms was not available in the medical
record, resulting in a final study cohort of 89 sub-
jects. Of these remaining subjects, 83 (93%) un-
derwent pretreatment brain MRI performed with
and without IV contrast material, and six (7%) un-
derwent unenhanced brain MRI only. Brain MRI
protocols varied on a case-by-case basis because
almost all pretreatment brain imaging examina-
tions were performed at outside centers; howev-
er, the brain MRI examinations typically included
axial fast spin-echo (FSE) unenhanced and con-
trast-enhanced T1-weighted images and either
FSE or spoiled gradient-recalled coronal contrast-
enhanced T1-weighted images.
Image Analysis
The imaging studies were reviewed by a board-
certified radiologist who was in the second year of
a neuroradiology fellowship to determine if the im-
aging signs of SIH were present or absent. If the
imaging findings for a patient were thought to be
equivocal, the imaging studies were reviewed by a
second board-certified radiologist who has a certif-
icate of added qualification in neuroradiology and
extensive experience in treating patients with SIH.
The presence of principal brain MRI signs of
SIH (i.e., dural enhancement, brain sagging, and
the venous distention sign) (Fig. 1) was assessed
using previously described criteria [4]. Dural en-
hancement was graded as follows: absent, abnor-
mal enhancement without dural thickening, or ab-
normal enhancement with dural thickening. The
presence of pituitary engorgement was not as-
sessed because we think that this sign is too sub-
jective for reproducible analysis and is of lesser
diagnostic significance in SIH.
CT myelograms were designated as showing
evidence of CSF leak if contrast material was seen
outside the thecal sac. Leaks were further subcat-
egorized as high-flow leaks or low-flow leaks us-
ing the following previously described criteria: A
leak was defined as a high-flow leak if leaked con-
trast material was seen spreading over more than
one vertebral level and as a low-flow leak if leaked
contrast material was seen spreading over one ver-
tebral level or less [10].
Statistical Analysis
Differences in symptom duration between sub-
jects for whom individual brain MRI signs of SIH
were present or absent were compared using a
two-sided t test. For subjects with abnormal du-
ral enhancement, differences in symptom duration
based on the degree of dural abnormality were
compared using the Mann-Whitney test. For CT
myelographic findings, a two-sided t test was used
to compare symptom duration between subjects
with a CSF leak and those without a CSF leak.
A one-way ANOVA was used to further compare

1284 AJR:207, December 2016

 Imaging Signs of SIH

200.0 t test p = 0.002 200.0 t test p = 0.010 200.0 t test p = 0.021

Symptom Duration (wk)

Symptom Duration (wk)

Symptom Duration (wk)

50.0 50.0 50.0

20.0 20.0 20.0

5.0 5.0 5.0

2.0 2.0 2.0

1.0 1.0 1.0
0.5 0.5 0.5

Absent Present Absent Present Absent Present

Dural Enhancement Brain Sagging Venous Distention Sign

A B C
Fig. 2—Box-and-whisker plots comparing symptom duration in patients with spontaneous intracranial hypotension (SIH) and brain MRI signs suggestive of SIH. Upper
and lower lines of boxes show first and third quartiles, respectively. Middle lines in boxes show median. Whiskers show minimum and maximum values, excluding
outliers.  = outliers.
A–C, Box-and-whisker plots show symptom duration in SIH patients with and in those without brain MRI signs of SIH. Brain MRI signs of SIH that were evaluated include
dural enhancement (A), brain sagging (B), and “venous distention” sign (C).

symptom duration on the basis of leak subtype nal study cohort, the mean age was 47.7 ± hancement was associated with a longer du-
(i.e., no leak, high-flow leak, low-flow leak). The 13.9 (SD) years (range, 18–83 years). Sixty ration of symptoms than the presence of dural
Fisher exact test was used to compare the preva- patients (67%) were female subjects, and 29 enhancement (average symptom duration,
American Journal of Roentgenology 2016.207:1283-1287.

lence of dural enhancement in patients who had patients (33%) were male subjects. A prior 45.3 ± 59.0 vs 15.1 ± 33.0 weeks, respectively;
received a prior epidural blood patch with that in blood patch had been attempted in 36 sub- p = 0.002). For subjects with abnormal dural
patients who had not. Analysis was performed us- jects (40%), whereas 53 subjects (60%) had enhancement, a subgroup analysis based on
ing statistical and computing software (R, version not been treated previously. The prevalence the degree of abnormality (i.e., abnormal en-
3.0.2, The R Foundation); p values of < 0.05 were of dural enhancement was not significant- hancement alone vs abnormal enhancement
considered to be statistically significant. ly different in the subgroup of patients who plus dural thickening) was not associated
had received prior blood patch (89%) com- with a significant difference in symptom du-
Results pared with the subgroup of those who had ration (p = 0.58). No difference in symptom
The mean duration of headache symptoms not (77%) (p = 0.25). duration was found between subjects showing
was 20.5 months (range, 9 days–240 months; Comparisons of symptom duration in pa- and those not showing brain sagging on brain
SD, 40.0 months). The distribution was tients with and those without brain MRI signs MRI (p = 0.10) or between subjects showing
skewed, however, with subjects having symp- of SIH are shown in Figure 2. Significant dif- and those not showing the venous distention
tom duration of less than 1 year accounting ferences in symptom duration were observed sign on brain MRI (p = 0.21).
for 67% of the population. As a result, the between subjects with dural enhancement on Of the 89 subjects, 37 (42%) showed no
median duration of symptoms was only 6.0 brain MRI compared with those without du- CSF leak, 45 (51%) had a high-flow leak, and
months (95% CI, 3.5–8.0 months). In the fi- ral enhancement. The absence of dural en- seven (8%) had a low-flow leak on CT my-

200.0 t test p = 0.56 200.0 ANOVA p = 0.003

Symptom Duration (wk)

Symptom Duration (wk)

50.0 50.0

20.0 20.0

5.0 5.0

2.0 2.0
1.0 1.0
0.5 0.5

Absent Present No Leak High-Flow Leak Low-Flow Leak

Leak on CT Myelography CT Myelography Findings

A B
Fig. 3—Box-and-whisker plots comparing symptom duration and CT myelography findings in patients with spontaneous intracranial
hypotension. Upper and lower lines of boxes show first and third quartiles, respectively. Middle lines in boxes show median. Whiskers
show minimum and maximum values, excluding outliers.  = outliers.
A, Box-and-whisker plot shows symptom duration in patients with and in those without CSF leak on CT myelography.
B, Box-and-whisker plot shows symptom duration in patients with CSF leak on CT myelography by subtype of CSF leak identified. Leak
was defined as high-flow leak if leaked contrast material was seen spreading over more than one vertebral level and as low-flow leak
if leaked contrast material was seen spreading over one vertebral level or less [10].

AJR:207, December 2016 1285


elography. Comparisons of symptom dura-
tion related to CT myelographic findings are
shown in Figure 3. Although there was no
overall difference in symptom duration be-
tween patients with no leak and those with
a leak (p = 0.56), there was a significant dif-
ference (p = 0.003) when the data were seg-
mented by leak subtype. Based on a one-way
ANOVA analysis, the duration of symp-
toms of subjects with high-flow leaks was
shorter relative to baseline (i.e., the no-leak
group), but this difference was not statistical-
ly significant (p = 0.17). However, subjects
with low-flow leaks were symptomatic 40.9
weeks (mean) longer than baseline (no-leak
group), a difference that was highly statisti-
cally significant (p = 0.01).
Discussion
Our investigation shows that the dural
enhancement seen in patients with SIH be-
American Journal of Roentgenology 2016.207:1283-1287.
comes less prevalent over time after the onset
of symptoms. The mean duration of headache
symptoms for subjects with dural enhance-
ment present was 15.1 weeks compared with
45.3 weeks for those with no dural enhance-
ment. Conversely, other less common imag-
ing findings including brain sagging and the
venous distention sign do not show similar
time-dependent variability, but these signs
are less frequently found in SIH overall. The
presence or absence of a CSF leak on CT my-
elography was not associated with differences
in symptom duration in general, with the ex-
ception of the low-flow subtype of leaks.
These findings have implications when
considering the diagnosis of SIH, particular-
ly in patients with symptoms of longer dura-
tion. Dural enhancement is the single most
common imaging sign found in patients with
SIH [4] and therefore is often relied on as a
major indicator of the condition. Failure to
account for the time-dependent decrease in
the prevalence of dural enhancement could
potentially contribute to underdiagnosis,
which is already a known problem [5]. Spe-
cifically, patients with chronic SIH whose
imaging studies no longer show dural en-
hancement would be less likely to be recog-
nized as suffering from the condition.
This problem of underdiagnosis could
be further compounded by the fact that the
headache phenotype in SIH also can change
with chronicity, evolving from positional
headaches into nonspecific headache symp-
toms that are less stereotypical of the condi-
tion. These changes may result in decreasing
headache severity or the disappearance of the
1286 AJR:207, December 2016
Kranz et al.
positional component of the headache alto-
gether and transformation into chronic daily
headache [7, 11]. The headache pattern may
evolve into a so-called “second-half-of-the-
day” headache in which the orthostatic com-
ponent is evident only over a longer period of
time upright [12] despite ongoing CSF leak-
age detectable on CT myelography. Thus, as
the clinical symptoms become less clearly in-
dicative of a diagnosis of SIH, the likelihood
of suggestive imaging abnormalities may also
decrease, further hindering diagnosis.
The observation that the prevalence of du-
ral enhancement changes with time contrib-
utes to the growing body of evidence that the
physiology associated with SIH is not static
and that various compensatory mechanisms
may contribute to variations in the clinical
and imaging presentation of the condition
over time. Defining these changes and how
to detect them could lead to improvements in
the management of patients currently diag-
nosed with SIH and could potentially lead to
a further broadening of the diagnostic crite-
ria as more variation is recognized.
Evidence of physiologic compensatory
mechanisms in SIH has been suggested by
several prior observations. First, SIH is as-
sociated with identifiable anatomic changes
in the caliber of the veins in the intracrani-
al compartment and within the spinal canal;
these changes are consistent with the tenets
of the Monro-Kellie doctrine that requires
the vascular space to expand as the CSF vol-
ume decreases [3]. Second, CSF pressure
is only weakly correlated with other objec-
tive indicators of CSF volume depletion such
as brain imaging findings of venous disten-
tion and brain sagging and is not significant-
ly correlated with dural enhancement or CT
myelographic evidence of CSF leakage [4].
These observations point to the influence of
compensatory physiologic processes that can
help maintain CSF pressure in some patients
despite ongoing CSF volume loss. Finally,
CSF pressure in patients with SIH shows a
statistically significant increase with the in-
creasing duration of symptoms indepen-
dent of the presence or absence of CT my-
elographically detectable CSF leakage, again
suggesting that the physiologic changes in-
duced by SIH vary in a manner that is par-
tially time-dependent [6].
The observation of time-dependent chang-
es in dural enhancement in this current inves-
tigation further reinforces this body of evi-
dence. Specifically, our results suggest that
compensatory mechanisms mitigate the ef-
fects of CSF volume depletion over time and
result in a decrease in the dilatation of blood
vessels within the dura, as necessitated by
the Monro-Kellie doctrine. This decreased
vasodilatation manifests as a decrease in du-
ral enhancement on MRI.
Our investigation also found that the like-
lihood of finding a CSF leak on CT myelog-
raphy was independent of symptom dura-
tion except in patients with low-flow leaks.
Therefore, in general, it cannot be conclud-
ed that the decreased prevalence of dural en-
hancement with time is caused by spontane-
ous cessation of CSF leaks. With regard to
the low-flow leaks, it is possible that some
of the subjects in our study cohort had leaks
that initially started out as more rapid but
that slowed over time because of partial con-
tainment of the leak.
Because there is no single test that func-
tions as the reference standard for the diag-
nosis of SIH, the decreased prevalence of
hallmark imaging signs such as dural en-
hancement poses challenges for diagnosing
SIH in patients who present for evaluation
later in the course of their symptoms. This
diagnosis is doubly challenging if the clini-
cal symptoms also are changing with time.
It is possible, perhaps even likely, that some
patients diagnosed with other chronic head-
ache syndromes such as new daily persistent
headache actually suffer from an occult pre-
sentation of SIH. These patients may exhib-
it different clinical or imaging features than
subjects with so-called “classic,” or stereo-
typical, presentations of SIH. Defining how
broad the disease spectrum may be and de-
fining how to best establish the diagnosis in
these patients remain important avenues for
future investigation.
Limitations of this study include our loca-
tion at a tertiary referral center, which could
have the potential to introduce spectrum
bias. However, most of our subjects had not
been treated elsewhere previously, and thus
our sample would likely be representative of
SIH patients in general. We do not have ret-
rospective data regarding headache severi-
ty, which could be a theoretic covariate that
could change with time. However, there are
no data, to our knowledge, to suggest that the
severity of headache influences the imaging
signs of SIH such as dural enhancement.
In conclusion, we found that dural en-
hancement is less likely to be present as
symptom duration increases in patients with
SIH. As a result, SIH may be less likely to be
diagnosed accurately in patients with long-

standing SIH given the importance placed on
brain imaging in the diagnostic evaluation of
the condition. Further investigation of the
time-dependent changes in the clinical pre-
sentation and physiologic changes accompa-
nying SIH is warranted.
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