Audiovestibular manifestations of intracranial hypotension: a descriptive clinical series.

BACKGROUND

Intracranial hypotension (IH) results from decreased cerebrospinal fluid (CSF) volume or pressure and typically presents with orthostatic headache. IH may also manifest with audiovestibular symptoms with variable association to endolymphatic hydrops (EH). However, the nature of this relationship remains unclear.

OBJECTIVES

To describe the clinical, audiometric, vestibular, and imaging characteristics of patients with IH presenting with cochleovestibular dysfunction.

METHODS

We conducted a retrospective observational study including 12 patients diagnosed with IH based on MRI findings between 2016 and 2025 in a tertiary referral center. Data included demographic, audiovestibular, neurological, and imaging results. Descriptive statistics including patients with and without EH on MRI were reported.

RESULTS

Twelve patients (mean age 53.4 ± 19.2 years; 50% female) with MRI-confirmed non iatrogenic IH were included. Orthostatic headache was present in 83.3% of cases. Audiovestibular symptoms were common, including tinnitus (66.7%), rotational vertigo (50.0%), positional vertigo (16.67%), instability (41.7%), ear fullness (41.7%), and hearing loss (41.7%). Audiometry revealed overall mild sensorineural hearing impairment, while vestibular testing showed largely preserved video head impulse test gains and minimal caloric deficits. Delayed post-contrast 3D FLAIR MRI identified EH in four patients (33.3%), with bilateral involvement in two (16.7%); all cases were classified as low-grade saccular hydrops.

CONCLUSIONS

Audiovestibular symptoms, including tinnitus and dizziness, may accompany IH. MRI evidence of EH may support the hypothesis of a potential underlying CSF–inner ear pressure interaction. Future prospective studies should explore mechanistic pathways linking CSF hypovolemia to cochleovestibular dysfunction and EH, and gather data from larger cohorts. At this stage, the therapeutic implications remain uncertain. To our knowledge, this is the first study to perform delayed 3D FLAIR MRI in a cohort of patients with IH and cochleovestibular symptoms.