Background: Spontaneous Intracranial Hypotension is secondary to a loss of cerebrospinal fluid (CSF) volume, which is usually caused by spontaneous CSF leaks1. Although this uncommon entity has a common presentation, its diagnosis, evaluation and treatment2 are challenging.
Case Report: A 39-year-old woman developed orthostatic headaches, pain in the posterior triangle of the neck and shoulders, as well as nausea and vomiting, without focal signal abnormalities. Her medical history includes hypothyroidism and two epidural anaesthesias prior to caesarean sections (2008 and 2015).
Pain treatment consisting of conservative measures, bed rest, 500/50mg of paracetamol/caffeine 8/8 hours, 250mg of naproxen 12/12 hours and 4mg of thiocolchicoside 8/8 hours was ineffective and meningitis was ruled out after a lumbar puncture.
A head MRI with intravenous injection of paramagnetic contrast material showed bilateral frontoparietal dural signal enforcement correlated with CSF hypotension. A spine CT scan combined with a myelography showed a meningeal leaking at the level of D3.  
With anesthesia’s collaboration, neurosurgery decided the epidural blood patch would be performed in the OR under aseptic technique and with radiologic guidance to identify the space between D6-D7. An epidural space puncture was performed with a G18 Tuohy needle, with loss of resistance at 4,5cm and 18ml of homologous blood were injected epidurally. 
The patient had an uneventful recovery and was discharged one week later without any symptoms;
Discussion: The anatomy of spontaneous CSF leak is frequently complex. CT myelography is the study of choice1 to locate the site of the leak and epidural blood patch is the main and most effective treatment.

References:
1.	Mokri Bahram, MD, FAAN, Spontaneous intracranial hypotension. American Academy of Neurology 2015; 21(4): 1086-1108.

2.	Maurya VK, Ravikumar BR, Intracraneal hypotension: an uncommon entity with common presentation. Med J Armed Forces India 2017.


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