Recommendations for the Management of Spontaneous Intracranial Hypotension With Spinal Longitudinal Epidural CSF Collection

BACKGROUND AND OBJECTIVES: Spontaneous intracranial hypotension (SIH) results from spinal CSF leakage. Epidural blood patch (EBP) is an important first-line treatment. However, pre-EBP, intra-EBP, and post-EBP practice varies widely owing to limited consensus guidance. We aimed to develop expert consensus statements to support clinical decision-making in SIH management, including peri-EBP practices, focusing on patients with spinal longitudinal epidural CSF collection (SLEC) before definitive leak type classification. METHODS: An international multidisciplinary Delphi process was conducted between January 2024 and July 2025, involving experts in neurology, neurosurgery, radiology, and anesthesiology. Consensus was defined a priori as ≥70% agreement for strong agreement, 60%-69% for partial agreement, and <60% for no consensus, based on a 5-point Likert scale in round 3. Responses were collected anonymously using an online survey platform, with summarized feedback from the previous round provided between rounds. RESULTS: Fourteen experts were invited, with 10, 9, and 9 participants in rounds 1, 2, and 3, respectively. Before EBP, bed rest was recommended for recent-onset SIH with severe orthostatic headache (88.9%); other conservative methods such as abdominal binder and hydration were considered not mandatory (90%). Semitargeted EBP was recommended as initial management for patients with extradural CSF collections (70%). Dynamic CT myelography was preferred for localization (70%). Post-EBP care was variable, particularly in bed rest duration, with most recommendations (70%) exceeding 12 hours. Definitions of clinical remission (80%) and radiologic remission (90%) were established. Radiologic follow-up after clinical remission was recommended (78%). No consensus was reached on follow-up strategies for persistent symptoms, although "doing nothing" was not recommended. No consensus was reached for persistent extradural CSF despite clinical remission, requiring an individualized approach. Light activity after EBP was recommended within a few days (70%). No consensus was reached on the optimal number of EBPs before invasive leak localization or surgical intervention. DISCUSSION: This Delphi study outlines expert recommendations and uncertainties for SIH management, including peri-EBP practices. This study incorporated the initial management strategy for patients in whom leak-type classification was incomplete. However, the treatment section primarily focused on the SLEC-positive setting and presumed ventral dural tears; lateral dural tears and CSF-venous fistulas warrant future consensus development.