Intracranial hypotension
ICD-10 G96.81 is a billable code used to indicate a diagnosis of intracranial hypotension.
Intracranial hypotension is a condition characterized by abnormally low cerebrospinal fluid (CSF) pressure, which can lead to a variety of neurological symptoms. This condition often arises from CSF leaks, which may occur due to trauma, surgical procedures, or spontaneous causes. Patients typically present with severe headaches, often described as orthostatic headaches that worsen when standing and improve when lying down. Other symptoms may include neck stiffness, nausea, vomiting, tinnitus, and visual disturbances. The pathophysiology involves a decrease in CSF volume, leading to reduced cushioning of the brain and spinal cord, which can result in pain syndromes and autonomic dysfunction. Diagnosis is often confirmed through imaging studies such as MRI or CT scans, which may reveal signs of low CSF volume or meningeal enhancement. Treatment options include conservative management with hydration and caffeine, as well as more invasive procedures like epidural blood patches to seal leaks. Understanding this condition is crucial for accurate coding and management.
Detailed neurological examination findings, imaging results, and treatment plans.
Patients presenting with severe headaches, post-surgical patients, and those with spontaneous CSF leaks.
Ensure clear documentation of the patient's history and any imaging studies performed to support the diagnosis.
Comprehensive pain assessments, treatment response evaluations, and any interventions performed.
Patients with chronic headaches or pain syndromes related to low CSF pressure.
Document the relationship between pain symptoms and intracranial hypotension to justify treatment approaches.
Used for diagnostic purposes in patients suspected of having intracranial hypotension.
Document indication for the procedure, patient consent, and any complications.
Neurologists should ensure thorough documentation of the patient's neurological status pre- and post-procedure.
Common causes include spontaneous CSF leaks, post-surgical complications, and trauma. Identifying the underlying cause is crucial for effective management.
Diagnosis typically involves a combination of clinical evaluation, imaging studies such as MRI or CT, and sometimes lumbar puncture to measure CSF pressure.
