Continuous epidural saline infusion for spontaneous intracranial hypotension with cortical vein thrombosis: illustrative case.

backgroundSpontaneous intracranial hypotension (SIH), caused by CSF leakage, typically presents with orthostatic headache. Cerebral venous thrombosis (CVT) is a rare but serious complication of SIH. Their coexistence is diagnostically challenging due to the rarity of both conditions and overlapping clinical features, complicating timely recognition. OBSERVATIONS: A 40-year-old woman presented with orthostatic headache and bilateral scapular pain. Imaging revealed SIH with diffuse dural enhancement, CVT adjacent to the superior sagittal sinus, and a thin left convexity subdural hematoma. Conservative management with continuous epidural saline infusion (CESI) was initiated, avoiding anticoagulation to minimize hemorrhage risk and epidural blood patch to prevent abrupt pressure changes. The patient showed rapid symptomatic improvement, and 5-month follow-up imaging confirmed complete resolution of CVT and SIH-related findings. LESSONS: This case emphasizes the need for vigilance in suspecting CVT in SIH patients, particularly when symptoms persist. CESI is a safe and effective alternative for high-risk cases with subdural hematoma, promoting gradual stabilization of intracranial pressure while minimizing complications. Clinicians should tailor treatment to individual risk profiles to optimize outcomes for this rare clinical entity. https://thejns.org/doi/10.3171/CASE25571.