Spontaneous intracranial hypotension (SIH) typically presents with a severe orthostatic headache, with an incidence of 5 per 100,000 people. It is more commonly seen in females, in the 4^th or 5^th decade, but may present at any age. Treatment includes IV fluids, bed rest and caffeine. Failing those measures, an epidural blood patch (EBP) can be attempted. Dynamic CT Myelography can demonstrate extravasation of contrast allowing accurate localization of cerebrospinal fluid (CSF) leakage, permitting the targeted placement of an EBP, potentially increasing its success and avoiding the need for surgical dural repair.

We report two cases of SIH, diagnostic techniques used to localize the CSF leak, and treatment outcomes.

Each patient underwent detailed history and physical exam. MRI confirmed SIH and CSF leak. Conservative treatment was attempted and failed in both patients.

1. Patient 1 was a 36-year-old female with marked horizontal end gaze nystagmus had an extensive CSF leak with no identified source on cine MRI. Dynamic CT myelography showed ventral contrast leak at T3-T4, and a large volume EBP was performed at that location.
   
   
2. Patient 2 was a 44-year-old male with abducens nerve palsy. MRI suggested a leak at T5 however EBP at T5 failed to relieve symptoms. Dynamic myelography suggested a leak at C3-C4, and EBP was performed at C7-T1 to avoid procedural risks higher in the cervical spine.
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Patient 1 experienced tinnitus and dizziness post myelography that resolved spontaneously. She experienced lasting relief of symptoms from the EBP. Patient 2 had two weeks of relief, but headache returned, so he underwent repeat EBP at C7-T1 with no recurrence.

Strongly positional headaches should prompt suspicion for SIH. Dynamic CT myelography is an underutilized technique to localize CSF leaks. We describe two cases where it was safely employed to target large volume EBP in patient with SIH.