Sex Differences in the Clinical Manifestations and Treatment Outcomes of Spontaneous Intracranial Hypotension: A Large Cohort Study

Abstract

Background Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether men and women should be managed differently. We aimed to determine sex differences in clinical profiles and treatment outcomes in spontaneous intracranial hypotension. Methods This was a retrospective analysis of a prospective cohort of consecutive spontaneous intracranial hypotension patients enrolled from a tertiary medical center between December 1997 and January 2021 and followed up for at least three months. Medical records and imaging findings were reviewed. The outcome of treatment responses to epidural blood patches and risks of subdural hematoma and surgical drainage were measured. Results In total, 442 patients with spontaneous intracranial hypotension (165M/277F, mean age 40.3 ± 10.0 years) were included in the analysis. Men had longer delays between disease onset and initial hospital presentation (20.8 ± 21.5 vs. 38.2 ± 67.4 days, P = .002), and were less likely to have nausea, vomiting, photophobia, and tinnitus compared with women (all P < .05) despite comparable radiologic findings. Among the 374 patients treated with epidural blood patches, men were more likely to fail the first epidural blood patch (58.0% vs. 39.0%, odds ratio [OR] = 2.2 [95% confidence interval = 1.4–3.3], P < .001). However, the cumulative response rates to up to two epidural blood patches were similar in men and women (86.2% vs. 87.7%, P = .680). Men were at a higher risk of having subdural hematoma (29.7% vs. 10.8%, OR = 3.5 [95% CI = 2.1–5.8], P < .001). Among patients with subdural hematoma, men had greater thickness (12.8 ± 4.3 vs. 8.1 ± 5.9 mm, P < .001) and were more likely to receive surgical drainage (55.1% vs. 10.0%, OR = 11.0 [95% CI = 3.0-41.3], P < .001) than women. Two of the three patients with mortality or significant disability were men, and the only death in women was attributed to the underlying malignancy. Conclusions Spontaneous intracranial hypotension in men is characterized by a delayed presentation, poorer response to the first epidural blood patch, and a higher risk of subdural hematoma. Caution should be exercised in the management of men with spontaneous intracranial hypotension, and more aggressive measures, such as early and/or multiple epidural blood patches, may be helpful.