Background: Intracranial hypotension (IH) among
patients with persistent cerebrospinal fluid (CSF)
leakage remains a challenging problem. The majority
of these cases resolve spontaneously with
conservative measures. The customary treatment
for IH is epidural blood patch (EBP). In some
cases, CSF leaks can persist for months or even
years despite multiple trials of EBP. To date, there
are only a limited number of published studies
documenting the percutaneous injection of fibrin
sealant for treatment of IH refractory to conservative
measures and EBP.
Objective: Our objective was to perform a literature
review and retrospective case series regarding
patients who underwent percutaneous injection of
fibrin sealant for treatment of refractory IH at our
institution.
Study Design: This case series used a singlecentered
retrospective observational study design
and literature review.
Setting: Patients in this case series were treated
at a community-based tertiary care medical center.
Methods: Five consecutive patients with the diagnosis
of IH refractory to conservative measures
and EBP who underwent percutaneous patching
with fibrin sealant were identified at our institution
between January 1, 2000 and January 1, 2016. A
retrospective chart review was performed and data
including demographics, characteristics, interventions,
clinical outcomes, and complications were
collected. A critical review of the current literature
regarding the percutaneous use of fibrin sealant for
treatment of IH was conducted.
Results: Four of the 5 patients (80%) experienced
no further symptoms of IH and no adverse events
were noted. One patient (20%) ultimately required
surgical duroplasty. Review of the current literature
showed a total of 2 prospective case series,
4 retrospective case series, and 11 case reports.
Our present case series and literature review demonstrated
that fibrin sealants were well-tolerated by
most patients and associated with low incidences
of complications and recurrence.
Limitations: This study is limited by the small retrospective
case series of 5 patients.
Conclusions: Percutaneous injection of fibrin sealant
may be considered in refractory cases of IH
when repeated trials of EBP have persistently failed.
It appears to be a highly effective, safe, and easy-touse
alternative therapy for patients with refractory IH
in an ambulatory setting. Our review of the literature
revealed only studies with low quality of evidence,
including case series and case reports. There is a
substantial need for high-quality studies and clinical
evidence to corroborate the efficacy and safety of
this percutaneous technique. However, this ideal is
very challenging because of the relative rarity and
heterogeneous etiologies of cases.
Keywords: Fibrin sealant, intracranial hypotension,
CSF leak, epidural blood patch, orthostatic
headache, refractory, quality of life, percutaneous
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