{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T17:09:40Z","timestamp":1790701780116,"version":"4.1.0"},"reference-count":35,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2025,9,23]],"date-time":"2025-09-23T00:00:00Z","timestamp":1758585600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2025,9,23]],"date-time":"2025-09-23T00:00:00Z","timestamp":1758585600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["headachejournal.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Headache"],"published-print":{"date-parts":[[2026,1]]},"abstract":"Abstract<\/jats:title>\n \n Objective<\/jats:title>\n \n This study evaluated cranial\n magnetic resonance<\/jats:styled-content>\n imaging (MRI) signs in patients with post\u2010dural puncture headache (\n PDPH<\/jats:styled-content>\n ) using an established assessment score developed for spontaneous intracranial hypotension (Bern score). We hypothesize that patients with chronic\n PDPH<\/jats:styled-content>\n do not have typical imaging features of intracranial hypotension.\n <\/jats:p>\n <\/jats:sec>\n \n Background<\/jats:title>\n \n PDPH<\/jats:styled-content>\n is a well\u2010known complication following an intentional or unintentional lumbar dural puncture with positional headache, neck stiffness, and hearing disturbances usually resolving within 14\u2009days. However, the chronic course of\n PDPH<\/jats:styled-content>\n is poorly represented in the third version of the International Classification of Headache Disorders (\n ICHD<\/jats:styled-content>\n \u20103). Moreover, data on the role of cranial\n MRI<\/jats:styled-content>\n in this cohort are lacking, but could facilitate care and management of chronic\n PDPH<\/jats:styled-content>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n In this post hoc retrospective case series based on a chart review, we identified 86 consecutive patients from a tertiary medical care center in Freiburg, Germany\u00a0between 01\/2018 and 10\/2024 with chronic\n PDPH<\/jats:styled-content>\n , defined as persisting symptoms for >14\u2009days post puncture and\/or persisting after one or more epidural blood patches (\n EBP<\/jats:styled-content>\n ). Inclusion criteria were history of lumbar puncture (\n LP<\/jats:styled-content>\n ) or unintended dural puncture (\n UDP<\/jats:styled-content>\n ) and contrast enhanced cranial\n MRI<\/jats:styled-content>\n for assessment of Bern score in all patients. Presence of epidural lumbar fluid was evaluated using heavily\n T2<\/jats:styled-content>\n \u2010weighted\n MRI<\/jats:styled-content>\n or computed tomography (\n CT)<\/jats:styled-content>\n myelography, whenever available (83\/86 patients). Data were reviewed independently and blinded by two radiologists.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Eighty\u2010six patients with chronic\n PDPH<\/jats:styled-content>\n (66 females; mean age of 38.8\u2009\u00b1\u200911.2\n SD<\/jats:styled-content>\n years) were included with\n LP<\/jats:styled-content>\n as primary cause in 72% (\n n<\/jats:italic>\n =62) and\n UDP<\/jats:styled-content>\n while peridural (synonymous epidural) anesthesia (\n PDA<\/jats:styled-content>\n ) in 28% (\n n<\/jats:italic>\n \u2009=\u200924). Median symptom duration was 220.0 (interquartile range [\n IQR]<\/jats:styled-content>\n 94.0\u2010474.0) days. Overall median Bern score was 2.0 (\n IQR<\/jats:styled-content>\n 1.0\u20103.0) with no significant differences between\n LP<\/jats:styled-content>\n versus\n PDA<\/jats:styled-content>\n (\n p<\/jats:italic>\n \u2009=\u20090.379). Local epidural fluid was present in 9\/83 (11%) cases with adequate imaging and accompanied by higher median Bern scores (5.0 vs. 2.0;\n p<\/jats:italic>\n \u2009=\u20090.026). Prior\n EBP<\/jats:styled-content>\n was linked to lower median Bern scores (1.0 vs. 3.5;\n p<\/jats:italic>\n \u2009<\u20090.001).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n \n Patients with chronic\n PDPH<\/jats:styled-content>\n predominantly present a low Bern score and rarely exhibit spinal epidural fluid. If present, spinal epidural fluid is accompanied by higher Bern score. Our findings highlight the unreliability of current\n MRI<\/jats:styled-content>\n diagnostics to detect patients with chronic\n PDPH<\/jats:styled-content>\n , which must not lead to a mitigation of the diagnosis or a refusal of treatment. Further research on\n MRI<\/jats:styled-content>\n markers is needed here.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1111\/head.15057","type":"journal-article","created":{"date-parts":[[2025,9,24]],"date-time":"2025-09-24T04:16:24Z","timestamp":1758687384000},"page":"193-201","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Patients with chronic post\u2010dural puncture headache do not have typical imaging features of intracranial hypotension: An\n MRI<\/scp>\n study using the Bern score"],"prefix":"10.1111","volume":"66","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-5797-6825","authenticated-orcid":false,"given":"Charlotte","family":"Zander","sequence":"first","affiliation":[{"name":"Department of Neuroradiology, Medical Center \u2013 University of Freiburg, Faculty of Medicine University of Freiburg Freiburg 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Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1468-3634","authenticated-orcid":false,"given":"Katharina","family":"Wolf","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical Center \u2013 University of Freiburg, Faculty of Medicine University of Freiburg Freiburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5881-6043","authenticated-orcid":false,"given":"Alexander","family":"Rau","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Medical Center \u2013 University of Freiburg, Faculty of Medicine University of Freiburg Freiburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hansj\u00f6rg","family":"Mast","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Medical Center \u2013 University of Freiburg, Faculty of Medicine University of Freiburg Freiburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7687-6098","authenticated-orcid":false,"given":"J\u00fcrgen","family":"Beck","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical Center \u2013 University of Freiburg, Faculty of Medicine University of Freiburg Freiburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7264-4807","authenticated-orcid":false,"given":"Horst","family":"Urbach","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Medical Center \u2013 University of Freiburg, Faculty of Medicine University of Freiburg Freiburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0555-7863","authenticated-orcid":false,"given":"Niklas","family":"L\u00fctzen","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Medical Center \u2013 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