Brain parenchyma deformation and strain in patients with spontaneous intracranial hypotension.

Overview

1. Department of Neurosurgery, Medical Center–University of Freiburg, Breisacher-Str. 64, 79106 Freiburg im Breisgau, Germany
2. German CSF Center, Medical Center–University of Freiburg, Freiburg, Germany
3. Department of Diagnostic and Interventional Neuroradiology, Medical Center–University of Freiburg, Freiburg, Germany
4. Department of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg, Freiburg, Germany

Abstract

Background: Spontaneous intracranial hypotension (SIH) is mainly associated with orthostatic headache but can also cause cognitive impairment, with symptoms mimicking behavioral-type frontotemporal dementia in severe cases. SIH is caused by a spinal cerebrospinal fluid (CSF) leak and can lead to brain sagging. The specific brain regions affected by this motion, their deformation, and the magnitude of the associated mechanical strain have not been quantitatively characterized. We investigated whether brain MRI in patients with SIH shows quantifiable strain, expansion, and compression of brain structures by comparing images before and after surgical occlusion of a spinal leak.

Methods: We performed a retrospective analysis of 96 patients with SIH who underwent surgical closure of a spinal CSF leak. We performed AI-assisted diffeomorphic registration of pre- and postoperative MRI. From the resulting displacement maps, we calculated the Jacobian determinant as an indicator of expansion and contraction, and the von Mises equivalent deviatoric strain as an indicator of distortion and shearing in brain regions. Results were compared with 61 healthy adults scanned twice over a comparable interval, and correlated with perioperative headache, quality-of-life and cognitive scores.

Results: Ventricles and transverse sinuses showed relevant perioperative expansion and contraction, respectively. Beyond these expected volumetric changes, significant deviatoric strain was observed in temporomesial and frontal structures, including the temporal poles (right/ left: 8.6/ 8.7%), hippocampus (9.0/ 9.8%), and basal forebrain (9.9/ 9.8%) (p < 0.001 for all), despite only moderate volumetric change in these regions. Deformation substantially exceeded that of healthy controls. Whole-brain strain showed a modest positive association with perioperative improvement in headache burden, whereas analyses of cognitive outcome were underpowered.

Conclusion: SIH is associated with quantifiable regional brain deformation resulting in region-specific mechanical strain. Elevated strain in fronto-limbic and temporomesial regions, implicated in behavioral and cognitive regulation, suggests a network-level mechanical effect that may contribute to the clinical presentation observed in severe SIH.

Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12987-026-00865-8.

Reproduced under the paper's license (CC BY), from the paper cited above.

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Data

Datasets cited

• figshare:33383991, at figshare; found in DataCite
• figshare:33383997, at figshare; found in DataCite
• figshare:33384000, at figshare; found in DataCite

Data availability

Parts of the dataset containing data from patients who agreed to share it with other researchers will be made available upon reasonable request to the corresponding author.

Reproduced under the paper's license (CC BY), from the paper cited above.

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Version 1, 27 September 2026: the first record

Recorded: type, language, journal, volume, issue, pages, dates, 9 authors, 10 keywords, 12 MeSH terms, 39 references.

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This paper

El Rahal, A., Beck, J., Wolf, K., Volz, F., Overstijns, M., Lützen, N., Zander, C., Urbach, H., & Scheffler, P. (2026). Brain parenchyma deformation and strain in patients with spontaneous intracranial hypotension. Fluids and barriers of the CNS, 23(1), 105. https://doi.org/10.1186/s12987-026-00865-8

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