BACKGROUND: Spontaneous intracranial hypotension is a challenging clinical entity, conventionally managed through epidural blood patching. In a subset of refractory patients who have exhausted all standard-of-care therapies, suboptimal response or recurrence are major clinical concerns and can lead to prolonged symptoms, repeated interventions, and a heavier healthcare burden. Therefore, we describe an innovative intervention—continuous epidural infusion of hydroxyethyl starch—for the treatment of spontaneous intracranial hypotension, which is intended to provide sustained modulation of epidural pressure and to potentially promote closure of cerebrospinal fluid leaks.

CASE REPORT: This retrospective case series included 4 individuals diagnosed with spontaneous intracranial hypotension, all with orthostatic headaches. Three had non-traumatic subdural hematomas, among whom 2 underwent hematoma evacuation along with intracranial pressure monitoring within the subdural space. In contrast to conventional management strategies, these patients were treated with continuous epidural infusion of hydroxyethyl starch via epidural catheterization, with infusion parameters titrated to clinical response and, when available, intracranial pressure measurements. All patients had favorable clinical outcomes, with marked symptom relief, functional recovery, and no recurrence during follow-up. No major neurological complications or rebound intracranial hypertension occurred.

CONCLUSIONS: The patients’ responses to continuous epidural infusion of hydroxyethyl starch were uniformly positive, offering a promising outlook for the treatment of spontaneous intracranial hypotension. Larger prospective studies are needed to confirm its safety and efficacy.

Keywords: Headache, Spontaneous Intracranial Hypotension, Subdural hematoma, Epidural Blood Patching, Continuous Epidural Infusion of Hydroxyethyl Starch