Advanced imaging and targeted treatments may identify and treat occult cerebrospinal fluid leaks in MRI-negative SIHAdvanced Imaging Helps Find Hidden Causes of Headaches

Frontiers in Medicine Published July 9, 2026 DOI ↗ Editorial oversight: Dr. Ji-eun Park, MD · Brain, Mind & Pain

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Key Takeaway

Consider advanced imaging and targeted repairs when standard MRI is negative but clinical suspicion of SIH remains high.

This systematic review evaluates the diagnostic accuracy and therapeutic outcomes for patients with spontaneous intracranial hypotension (SIH) who present with MRI-negative findings. The authors synthesize evidence regarding advanced imaging modalities, including CT myelography, MR myelography, and digital subtraction myelography (DSM), to identify occult cerebrospinal fluid (CSF) leaks and CSF-venous fistulas.

The review indicates that patients with MRI-negative SIH often share core clinical symptoms with those who have positive findings but may experience longer symptom durations and higher recurrence rates. Advanced imaging techniques, particularly DSM, are noted as potentially effective tools for identifying hidden leaks. Regarding treatment, the authors suggest that epidural blood patches may provide benefit in selected cases, while targeted surgical repairs of identified leaks or CSF-venous fistulas may be associated with high rates of clinical improvement.

A key finding is that an absence of typical findings on a standard brain MRI should not rule out a diagnosis of SIH. However, the review notes that treatment benefits are described as possible or associated with high rates in selected patients rather than universal outcomes. The evidence suggests these interventions may be necessary for certain subsets of patients to achieve clinical improvement.

Some people experience severe headaches and other symptoms caused by a condition called spontaneous intracranial hypotension (SIH). This happens when cerebrospinal fluid leaks from the spine. In many cases, a standard brain MRI may not show any issues, making it difficult for doctors to find the cause of the pain.

This review looked at how advanced imaging tools like CT myelography and digital subtraction myelography can help. These specialized tests were found to be more effective at finding hidden leaks that regular scans might miss. Identifying these specific leaks is important because patients with these hidden cases often experience longer symptoms and higher rates of recurrence.

Once a leak is found, treatments such as an epidural blood patch or targeted surgical repairs may provide clinical benefits. Because standard scans do not always show the full picture, advanced imaging is a valuable tool for doctors to find the right treatment for patients with persistent symptoms.

What this means for you:

Advanced imaging can help identify hidden spinal fluid leaks when standard brain MRIs do not show any issues.

Common questions

What happens if a standard MRI doesn't show anything?

If a standard brain MRI is negative, it does not mean the condition is not present. A significant minority of patients with this condition have hidden leaks that are only visible through advanced imaging like CT myelography or digital subtraction myelography.

How do these symptoms differ in cases where scans are normal?

Patients whose conditions are not caught on initial scans often share the same core symptoms as those who are. However, they may experience a longer duration of symptoms and have higher rates of recurrence.

What treatments are available for these hidden leaks?

Once a leak is identified through advanced imaging, an epidural blood patch may provide clinical benefit. Targeted surgical repairs of the specific leaks also show high rates of clinical improvement in selected patients.

Study Details

Study typeMeta analysis

EvidenceLevel 1

PublishedJul 2026

View Original Abstract ↓

BackgroundSpontaneous intracranial hypotension (SIH) is a debilitating syndrome typically characterized by orthostatic headache and classic brain MRI findings. However, brain MRI abnormalities are indirect manifestations of cerebrospinal fluid (CSF) volume depletion rather than direct evidence of the leak, and some patients may present with unrevealing or absent typical brain MRI findings, posing a considerable diagnostic challenge.MethodsA comprehensive search of PubMed/Medline, Web of Science, and Scopus was conducted to perform a systematic review, according to PRISMA guidelines, analyzing the available evidence on MRI-negative SIH (patients without typical SIH findings on their initial brain MRI), including its clinical features, advanced diagnostic strategies, and therapeutic outcomes.ResultsThis analysis reveals that, in selected cohorts, brain MRI-negative SIH has been reported in a substantial minority of patients, sharing core clinical symptoms with MRI-positive SIH but often associated with longer symptom duration and higher recurrence rates. While standard qualitative brain MRI without dedicated spinal imaging or dynamic myelographic techniques is often unrevealing, advanced modalities such as CT myelography, MR myelography, and particularly digital subtraction myelography (DSM) may help to identify occult cerebrospinal fluid (CSF) leaks, including CSF-venous fistulas. Treatment with epidural blood patch may provide clinical benefit in selected patients, while targeted surgical repair of demonstrated leaks or CSF–venous fistulas may be associated with high rates of clinical improvement.ConclusionIn patients with a clinical presentation suggestive of SIH, the absence of typical brain MRI findings should not automatically exclude the diagnosis but should prompt further diagnostic evaluation to improve patients’ outcomes.Systematic review registrationCRD420251146583. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251146583

Advanced imaging and targeted treatments may identify and treat occult cerebrospinal fluid leaks in MRI-negative SIHAdvanced Imaging Helps Find Hidden Causes of Headaches

Common questions

Study Details

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Advanced imaging and targeted treatments may identify and treat occult cerebrospinal fluid leaks in MRI-negative SIHAdvanced Imaging Helps Find Hidden Causes of Headaches

Common questions

Study Details

Intravenous tenecteplase improves functional outcomes but increases hemorrhage risk in non-large vessel occlusion acute ischemic stroke

Tenecteplase improves stroke recovery but increases bleeding risk in late treatment window

Clinical research that matters. Delivered to your inbox.

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