Intracranial hypotension, spontaneous
ICD-10 G96.811 is a billable code used to indicate a diagnosis of intracranial hypotension, spontaneous.
Intracranial hypotension, spontaneous, is a condition characterized by a decrease in cerebrospinal fluid (CSF) pressure without an identifiable cause. This condition can lead to a variety of symptoms, primarily severe headaches that are often positional, worsening when the patient is upright and improving when lying down. Other symptoms may include neck stiffness, nausea, vomiting, visual disturbances, and tinnitus. The pathophysiology involves a reduction in CSF volume, which can result from CSF leaks, often due to spontaneous dural tears. This condition can also lead to secondary complications such as autonomic dysfunction, which may manifest as orthostatic hypotension, and can contribute to the development of hydrocephalus due to compensatory mechanisms. Diagnosis typically involves clinical evaluation, imaging studies such as MRI or CT scans, and sometimes lumbar puncture to measure CSF pressure. Treatment may include conservative measures like hydration and caffeine intake, or more invasive procedures such as epidural blood patches to seal leaks. Understanding the nuances of this condition is crucial for accurate coding and management.
Detailed neurological examination findings, imaging results, and treatment plans.
Patients presenting with severe headaches, neck stiffness, and autonomic symptoms.
Ensure clear documentation of the patient's positional headache characteristics and any imaging studies performed.
Comprehensive pain assessments, treatment history, and response to interventions.
Management of chronic headache syndromes related to intracranial hypotension.
Document the impact of pain on daily activities and any multimodal treatment approaches.
Used to confirm low CSF pressure in suspected cases of intracranial hypotension.
Document indication for the procedure, findings, and any complications.
Neurology specialists should ensure thorough documentation of the patient's neurological status pre- and post-procedure.
Common symptoms include severe positional headaches, neck stiffness, nausea, vomiting, and visual disturbances. Symptoms typically worsen when the patient is upright and improve when lying down.
Diagnosis is made through clinical evaluation, imaging studies such as MRI or CT scans, and lumbar puncture to measure cerebrospinal fluid pressure.
Treatment may include conservative measures such as hydration and caffeine intake, or more invasive procedures like epidural blood patches to seal CSF leaks.
