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The contribution of lumbar puncture opening pressure in the diagnosis of spontaneous intracranial hypotension: A systematic literature review and meta‐analysis.

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Title: The contribution of lumbar puncture opening pressure in the diagnosis of spontaneous intracranial hypotension: A systematic literature review and meta‐analysis.
Authors: Parikh, Simy K. (AUTHOR), Deline, Constance R. (AUTHOR), McCreary, Morgan (AUTHOR), Amoozegar, Farnaz (AUTHOR), Amrhein, Tim J. (AUTHOR), Carroll, Ian R. (AUTHOR), Cutsforth‐Gregory, Jeremy K. (AUTHOR), Leithe, Linda G. (AUTHOR), Kranz, Peter G. (AUTHOR), Louy, Charles (AUTHOR), Maya, Marcel M. (AUTHOR), Moghekar, Abhay (AUTHOR), Rau, Jill (AUTHOR), Silberstein, Stephen (AUTHOR), Schievink, Wouter I. (AUTHOR), Friedman, Deborah I. (AUTHOR)
Source: Headache: The Journal of Head & Face Pain. Feb2026, Vol. 66 Issue 2, p517-530. 14p.
Subjects: Diagnosis of brain diseases, Research funding, Meta-analysis, Descriptive statistics, Systematic reviews, MEDLINE, Odds ratio, Medical databases, Online information services, Confidence intervals, Data analysis software, Lumbar puncture, Cerebrospinal fluid
Abstract: Objective: The objective of this study was to summarize the available evidence regarding the clinical value and trend over time of lumbar cerebrospinal fluid (CSF) opening pressure utilization to diagnose spontaneous intracranial hypotension (SIH). Background: CSF opening pressure obtained via lumbar puncture is one of the diagnostic criteria for SIH based on the International Criteria for Headache Disorders, 3rd Edition (ICHD‐3), but it has questionable utility as an initial investigation for diagnosing SIH. Methods: The authors performed a systematic literature review and meta‐analysis. PubMed/MEDLINE, Scopus, and Cochrane Library were searched from inception to October 2022. Original studies and case series in English reporting three or more patients with suspected or known SIH and CSF pressure measurement were included. Meta‐analyses and meta‐regression were used to calculate pooled estimates and examine the impact of age, sex, and publication year on outcomes, including CSF pressure < 60 mm CSF, orthostatic headache, and positive findings on brain magnetic resonance imaging (MRI), spinal imaging, and radionuclide studies. Results: For every 1‐year increase in the year of publication, the odds of reporting low CSF pressure decreased by 6.20% (adjusted odds ratio [aOR] = 0.94, aOR 95% confidence interval [CI] = [0.90, 0.97], p = 0.001), the odds of reporting a positive brain MRI increased by 4.67% (aOR = 1.05, aOR 95% CI = [1.01, 1.09], p = 0.026), and the odds of reporting orthostatic headache increased by 9.13% (aOR = 1.09, aOR 95% CI = [1.03, 1.15], p = 0.002). Each 1% increase in the percentage of patients with orthostatic headache was associated with a 3.13% increase in the odds of low CSF pressure (aOR = 1.03, aOR 95% CI = [1.01, 1.05], p = 0.003). Similarly, as the percentage of patients with low CSF pressure increased by 1%, there was a 2.53% increase in the odds of orthostatic headache (aOR = 1.03, aOR 95% CI = [1.01, 1.04], p = 0.005). It was estimated that 31.9% of patients with SIH had normal opening pressure (95% CI = [24.0%, 40.8%], prediction interval = [5.0%, 80.5%]). Every 1% increase in the percentage of patients with positive brain MRI was associated with a 5.25% increase in the odds of positive spinal imaging (aOR = 1.05, aOR 95% CI = [1.00, 1.11], p = 0.047). Age and positive radionuclide study did not significantly impact the outcomes measured. The corresponding I2 for each outcome was reduced by controlling for study‐wide covariates believed to impact the prevalence of each outcome. Sensitivity analyses did not reveal discrepancies in results when studies requiring outcomes of interest were removed. Conclusion: Our analysis found that recent studies indicate a reduced reliance on opening pressure for diagnosing SIH. Rather, results suggest an increasing reliance on contrast‐enhanced brain MRI, spine imaging, and clinical features for SIH diagnosis. Plain Language Summary: Spontaneous intracranial hypotension (SIH) is often referred to as "low pressure" and the measurement of cerebrospinal fluid (CSF) pressure is a key criterion for diagnosing SIH; however, the spinal fluid pressure as measured during a spinal tap (i.e., lumbar puncture [LP]) is frequently normal or even high in patients with SIH. This systematic literature review, which evaluated the clinical usefulness of measuring the CSF opening pressure to diagnose SIH, found that more recent studies have shown a decreased reliance on CSF opening pressure and an increased reliance on clinical features and brain and spine imaging for diagnosing SIH. This supports the idea of de‐emphasizing LP‐opening pressure as a diagnostic criterion for SIH. [ABSTRACT FROM AUTHOR]
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Database: Psychology and Behavioral Sciences Collection
Description
Abstract:Objective: The objective of this study was to summarize the available evidence regarding the clinical value and trend over time of lumbar cerebrospinal fluid (CSF) opening pressure utilization to diagnose spontaneous intracranial hypotension (SIH). Background: CSF opening pressure obtained via lumbar puncture is one of the diagnostic criteria for SIH based on the International Criteria for Headache Disorders, 3rd Edition (ICHD‐3), but it has questionable utility as an initial investigation for diagnosing SIH. Methods: The authors performed a systematic literature review and meta‐analysis. PubMed/MEDLINE, Scopus, and Cochrane Library were searched from inception to October 2022. Original studies and case series in English reporting three or more patients with suspected or known SIH and CSF pressure measurement were included. Meta‐analyses and meta‐regression were used to calculate pooled estimates and examine the impact of age, sex, and publication year on outcomes, including CSF pressure < 60 mm CSF, orthostatic headache, and positive findings on brain magnetic resonance imaging (MRI), spinal imaging, and radionuclide studies. Results: For every 1‐year increase in the year of publication, the odds of reporting low CSF pressure decreased by 6.20% (adjusted odds ratio [aOR] = 0.94, aOR 95% confidence interval [CI] = [0.90, 0.97], p = 0.001), the odds of reporting a positive brain MRI increased by 4.67% (aOR = 1.05, aOR 95% CI = [1.01, 1.09], p = 0.026), and the odds of reporting orthostatic headache increased by 9.13% (aOR = 1.09, aOR 95% CI = [1.03, 1.15], p = 0.002). Each 1% increase in the percentage of patients with orthostatic headache was associated with a 3.13% increase in the odds of low CSF pressure (aOR = 1.03, aOR 95% CI = [1.01, 1.05], p = 0.003). Similarly, as the percentage of patients with low CSF pressure increased by 1%, there was a 2.53% increase in the odds of orthostatic headache (aOR = 1.03, aOR 95% CI = [1.01, 1.04], p = 0.005). It was estimated that 31.9% of patients with SIH had normal opening pressure (95% CI = [24.0%, 40.8%], prediction interval = [5.0%, 80.5%]). Every 1% increase in the percentage of patients with positive brain MRI was associated with a 5.25% increase in the odds of positive spinal imaging (aOR = 1.05, aOR 95% CI = [1.00, 1.11], p = 0.047). Age and positive radionuclide study did not significantly impact the outcomes measured. The corresponding I2 for each outcome was reduced by controlling for study‐wide covariates believed to impact the prevalence of each outcome. Sensitivity analyses did not reveal discrepancies in results when studies requiring outcomes of interest were removed. Conclusion: Our analysis found that recent studies indicate a reduced reliance on opening pressure for diagnosing SIH. Rather, results suggest an increasing reliance on contrast‐enhanced brain MRI, spine imaging, and clinical features for SIH diagnosis. Plain Language Summary: Spontaneous intracranial hypotension (SIH) is often referred to as "low pressure" and the measurement of cerebrospinal fluid (CSF) pressure is a key criterion for diagnosing SIH; however, the spinal fluid pressure as measured during a spinal tap (i.e., lumbar puncture [LP]) is frequently normal or even high in patients with SIH. This systematic literature review, which evaluated the clinical usefulness of measuring the CSF opening pressure to diagnose SIH, found that more recent studies have shown a decreased reliance on CSF opening pressure and an increased reliance on clinical features and brain and spine imaging for diagnosing SIH. This supports the idea of de‐emphasizing LP‐opening pressure as a diagnostic criterion for SIH. [ABSTRACT FROM AUTHOR]
ISSN:00178748
DOI:10.1111/head.15060