Out of the Reading Room: The Case for Patient-Facing Neuroradiology in Spinal CSF Leak Care

BACKGROUND: The diagnosis of spinal CSF leak rests on tests that are individually imperfect and still evolving. A normal brain MRI does not exclude a leak, spine MRI cannot detect CSF-venous fistulas, and advanced myelography is technique dependent. As a result, a negative study often reflects the limits of the method or its sensitivity rather than the true absence of disease, yet it is frequently communicated to patients and referring clinicians as a definitive answer. A 'classic' orthostatic headache, long treated as the entry criterion for spontaneous intracranial hypotension (SIH), captures only part of the disease and may be least reliable in patients with CSF-venous fistulas. These gaps contribute to well-documented diagnostic delays. This article considers how the neuroradiologist's role might extend beyond the signed report to address them. METHODS: This State of Practice synthesizes current evidence on brain and spinal MRI, dynamic myelographic technique, empiric patching, and the patient diagnostic experience, together with the perspective of a neuroradiology practice subspecialized in spinal CSF leak imaging and treatment. KEY MESSAGE: For selected patients with suspected SIH, the neuroradiologist's role should extend beyond issuing a report. These include patients whose phenotype and imaging disagree, who remain symptomatic despite a "negative" study, or who face escalating procedural choices. In such cases the neuroradiologist is often best positioned to turn imaging uncertainty into a decision through a focused, patient-facing consultation: reconciling phenotype with imaging, auditing whether prior testing matched the suspected leak type, directing the next best step, and weighing the cost of each option with the patient. Its value should be measured against the patient's entire diagnostic odyssey, not a single imaging report. A negative study lowers the probability of a leak; it does not reduce it to zero. Better care may require neuroradiologists to step out of the reading room.