Temporal and regional trends in the diagnosis and treatment of spontaneous intracranial hypotension: a systematic review

Spontaneous intracranial hypotension (SIH) is an underrecognized condition with rapidly evolving diagnostic and therapeutic strategies. This study investigated temporal and regional trends in diagnostic and therapeutic modalities for SIH in the published literature. We systematically reviewed SIH-related clinical studies in PubMed from inception through December 2024. Data on study site (continent/country/institute) and diagnostic and treatment modalities used in clinical settings were extracted. To assess temporal and regional trends, the reported use of each modality was analyzed over 5-year intervals and across regions, separately for case reports and original articles, which respectively reflect real-world and research settings. A total of 789 articles (529 case reports and 260 original articles) were included. In case reports, brain MRI (84.4%), lumbar puncture (84.4%), and RI cisternography (50%) were the most frequently used diagnostics in 1990–1999, while brain MRI (91.1%) and spine MRI (74.8%) became predominant in 2020–2024. The use of lumbar puncture and RI cisternography declined to 24.4% and 5.9%, respectively, while dynamic CT myelography (18.5%) and digital subtraction myelography (23.7%) became more common in 2020–2024. Conservative management (81.3%) was the most common treatment in 1990–1999, while surgical repair increased to 39.8% in 2020–2024. Similar trends were observed in original articles. These temporal trends were similar across regions; however, in 2020–2024, dynamic CT myelography, DSM, and surgical repair were reported more frequently in publications from North America and Europe than in those from Asia (dynamic CT myelography: 35.4% and 22.0% vs. 4.7%; DSM: 40.8% and 33.0% vs. 6.7%; surgical repair: 59.3% and 42.5% vs. 13.6%). Diagnostic and therapeutic modalities for SIH have markedly shifted over time, reflecting the actual changes both in real-world practice and academic settings. Standardized diagnostic and treatment guidelines and broader global awareness of evolving practice are warranted.