Definitive minimally invasive treatment of spontaneous intracranial hypotension (SIH) is challenging due to heterogeneous mechanisms and locations of spinal cerebrospinal fluid (CSF) leaks. We evaluated CT-guided percutaneous cyanoacrylate injection for spinal CSF leaks.

We retrospectively reviewed consecutive SIH patients with CT myelography–confirmed leaks treated at our institution (2016–2025). Under local anesthesia, leak-type–tailored approaches were used: transforaminal or interlaminar for type 1 (dural tears) and posterior foraminal for types 2 (lateral leaks) and 3 (CSF-venous fistulas). Outcomes included HIT-6 and Bern scores (follow-up brain MRI only; post-treatment spine MRI not routinely performed). Paired t-tests compared baseline with primary follow-up (last post-cyanoacrylate assessment preceding any subsequent intervention).

Forty-four patients (mean age, 48.6 years, 25 women) underwent cyanoacrylate injection. Leak-type distribution: type 1 in 20/44 (45.5%), type 2 in 12/44 (27.3%), type 3 in 12/44 (27.3%). In total, 50 sites were treated; 5 patients (11.4%) had multiple sites addressed in one session. Mean procedure duration was 28.8 ± 6.5 minutes. No intraprocedural complications or neurologic deficits occurred. Transient (< 24 h) post-procedural locoregional pain occurred in 12/44 (27.3%). Mean follow-up was 16.3 ± 11.6 months. Mean HIT-6 decreased from 66.8 ± 2.9 to 40.0 ± 6.6 ( p < 0.001), and Bern score from 7.2 ± 1.2 to 1.5 ± 1.5 ( p < 0.001) on follow-up MRI (mean, 2.2 months). Favorable clinical outcomes occurred in 37/44 (84.1%): complete symptom resolution in 30 (68.2%) and subtotal in 7 (15.9%). Five (11.4%) with partial improvement underwent complementary posterior epidural blood patch at the index level and subsequently achieved favorable outcomes; 2/44 (4.5%) had no improvement and were referred for surgery.

These findings support CT-guided percutaneous cyanoacrylate as a versatile, effective, and safe therapy across SIH leak types, with high rates of favorable clinical outcomes and concordant brain imaging improvement. Future studies with standardized post-treatment spine imaging are needed to enable assessment of an anatomic closure endpoint, validate efficacy by leak type, and define this technique’s role relative to other therapies.