The diagnosis of CSF-venous fistulas represents a paradigm shift in the management of spontaneous intracranial hypotension, moving from a search for fluid collections to a hunt for hyperdynamic venous shunts. Our review demonstrates that while the Bern Score provides a robust initial stratification framework, its application requires nuance: recent evidence suggests that isolated cistern effacement measures may yield false positives in normal individuals, underscoring the need for a holistic assessment.

Therefore, integrating high-probability MRI screening with lateral decubitus dynamic myelography is non-negotiable. This positioning leverages gravity to overcome the limitations of conventional techniques, exposing fistulas that would otherwise remain occult.

By strictly following this roadmap, screening with a critical eye on the Bern Score and hunting with optimized decubitus myelography, radiologists can confidently identify the "hyperdense paraspinal vein," differentiate actual pathology from incidental diverticula or anatomic variants, and facilitate curative endovascular or surgical treatment for this often-debilitating condition.