scholarly journals Spontaneous Intracranial Hypotension and the durability of Epidural Blood Patch

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Ali Hazama ◽  
Lori John ◽  
Alexander E Braley ◽  
Lawrence S Chin ◽  
Satish Krishnamurthy
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Symptomatic Relief ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
Brain Magnetic Resonance Imaging ◽  
Definitive Treatment ◽  
Csf Leak ◽  
Persistent Symptoms ◽  
Blood Patch

Abstract INTRODUCTION Spontaneous Intracranial Hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate recent efficacy and outcomes of EBP for SIH at our institution. We also sought to explore the viability of repeat blood patches for patients whose symptoms persisted or recurred. METHODS A total of 23 patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018. All patients underwent brain magnetic resonance imaging (MRI) with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBPs were placed at 1-2 vertebral levels below identified or suspected areas of leak. Patients were seen within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 mo following clinical relief of symptoms. RESULTS 22/23 (95.7%) patients presented with complaints of orthostatic headache, 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningial enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, 5/23 (21.7%) patients received repeat EBPs for persistent symptoms will all achieving relief after repeat EBP. About 5/12 (41.7%) patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient was 21.7 mL. In total, 18/23 (78.2%) patients are currently asymptomatic with regards to their SIH. Mean follow-up in this cohort was 2.6 yr. CONCLUSION EBP is a viable option for the treatment of SIH caused by CSF leak. Repeat epidural blood patch is reasonable in cases of recurrent symptoms.

scholarly journals Comparisons of clinical characteristics, brain MRI findings, and responses to epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache: retrospective study

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Gha-Hyun Lee ◽  
Jiyoung Kim ◽  
Hyun-Woo Kim ◽  
Jae Wook Cho
Keyword(s):  
Intracranial Hypotension ◽  
Dural Puncture ◽  
Epidural Blood Patch ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
Vein Of Galen ◽  
Mri Findings ◽  
Post Dural Puncture Headache ◽  
Straight Sinus ◽  
Blood Patch

Abstract Background Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment. Methods We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus). Results A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02). Conclusions Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

scholarly journals Targeted CT-Guided Epidural Blood Patch for Treatment of Spontaneous Intracranial Hypotension Due to Calcified Intradural Thoracic Disc Herniation

2013 ◽  
Vol 19 (1) ◽  
pp. 121-126 ◽  
Author(s):  
V. Agarwal ◽  
G. Sreedher ◽  
W.E. Rothfus
Keyword(s):  
Disc Herniation ◽  
Epidural Space ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Fluoroscopic Guidance ◽  
Ct Guided ◽  
Blood Patch ◽  
Disc Herniations

Calcified thoracic intradural disc herniations have recently been reported as a cause of spontaneous intracranial hypotension (SIH). We report successful treatment of SIH with a targeted CT-guided epidural blood patch. A 57-year-old man presented to the emergency department with a two-week history of progressively debilitating headache. CT and MRI of the brain showed findings consistent with intracranial hypotension and MRI of the spine showed findings consistent with CSF leak. Subsequent CT myelogram of the thoracic spine confirmed the presence of CSF leak and calcified disc herniations at the T6-7, T7-8 and T8-9 levels indenting the ventral dura and spinal cord. The calcified disc herniation at T6-7 had an intradural component and was therefore the most likely site of the CSF leak. Under CT fluoroscopic guidance, a 20-gauge Tuohy needle was progressively advanced into the dorsal epidural space at T6-7. After confirmation of needle tip position, approximately 18cc of the patient's own blood was sterilely removed from an arm vein and slowly re-injected into the dorsal epidural space. With satisfactory achievement of clot formation, the procedure was terminated. The patient tolerated the procedure well. The next morning, his symptoms had completely resolved and he was neurologically intact. At five-week follow up, he was symptom-free. Targeted epidural blood patch at the site of presumed CSF leak can be carried out in a safe and effective manner using CT fluoroscopic guidance and can be an effective alternative to open surgical management in selected patients.

scholarly journals Spontaneous Intracranial Hypotension Treated with a Targeted CT-Guided Epidural Blood Patch

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
Inês Correia ◽  
Inês Brás Marques ◽  
Rogério Ferreira ◽  
Miguel Cordeiro ◽  
Lívia Sousa
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Complete Recovery ◽  
Csf Leak ◽  
Ct Guided ◽  
Blood Patch ◽  
History Of ◽  
Persistent Headache ◽  
Csf Leaks

Spontaneous intracranial hypotension (SIH) is an important cause of new daily persistent headache. It is thought to be due to spontaneous spinal cerebrospinal fluid (CSF) leaks, which probably have a multifactorial etiology. The classic manifestation of SIH is an orthostatic headache, but other neurological symptoms may be present. An epidural blood patch is thought to be the most effective treatment, but a blind infusion may be ineffective. We describe the case of a young man who developed an acute severe headache, with pain worsening when assuming an upright posture and relief gained with recumbency. No history of previous headache, recent cranial or cervical trauma, or invasive procedures was reported. Magnetic resonance imaging showed pachymeningeal enhancement and other features consistent with SIH and pointed towards a cervical CSF leak site. After failure of conservative treatment, a targeted computer tomography-guided EBP was performed, with complete recovery.

scholarly journals Targeted Epidural Blood Patch Treatment for Refractory Spontaneous Intracranial Hypotension in China

2017 ◽  
Vol 79 (03) ◽  
pp. 217-223 ◽  
Author(s):  
Fei-Fang He ◽  
Li Li ◽  
Min-Jun Liu ◽  
Tai-Di Zhong ◽  
Qiao-Wei Zhang ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Persistent Symptoms ◽  
Ionic Contrast ◽  
Blood Patch ◽  
Csf Leakage ◽  
Whole Spine ◽  
Mr Myelography ◽  
Csf Leaks

Objective An epidural blood patch (EBP) is the mainstay of treatment for refractory spontaneous intracranial hypotension (SIH). We evaluated the treatment efficacy of targeted EBP in refractory SIH. Methods All patients underwent brain magnetic resonance imaging (MRI) with contrast and heavily T2-weighted spine MRI. Whole spine computed tomography (CT) myelography with non-ionic contrast was performed in 46 patients, and whole spine MR myelography with intrathecal gadolinium was performed in 119 patients. Targeted EBPs were placed in the prone position one or two vertebral levels below the cerebrospinal fluid (CSF) leaks. Repeat EBPs were offered at 1-week intervals to patients with persistent symptoms, continued CSF leakage, or with multiple leakage sites. Results Brain MRIs showed pachymeningeal enhancement in 127 patients and subdural hematomas in 32 patients. One hundred fifty-two patients had CSF leakages on heavily T2-weighted spine MRIs. CSF leaks were also detected on CT and MR myelography in 43 and 111 patients, respectively. Good recovery was achieved in all patients after targeted EBP. No serious complications occurred in patients treated with targeted EBP during the 1 to 7 years of follow-up. Conclusions Targeted and repeat EBPs are rational choices for treatment of refractory SIH caused by CSF leakage.

Spontaneous intracranial hypotension combined with subarachnoid hemorrhage: report of 2 cases

2020 ◽  
Author(s):  
Ya Cao ◽  
Weinan Na ◽  
Hui Su ◽  
Xiaolin Wang ◽  
Zhao Dong ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Brain Mri ◽  
Intrathecal Injection ◽  
Spontaneous Intracranial Hypotension ◽  
Orthostatic Headache ◽  
Csf Pressure ◽  
Brain Ct ◽  
Blood Patch

Abstract Background: Spontaneous intracranial hypotension (SIH) combined with subarachnoid hemorrhage (SAH) has rarely been reported. Herein, we report two patients with SIH who suffered from diffuse non-aneurysmal SAH and expanded the symptom spectrum of SIH.Case report: ① A 55-year-old male was diagnosed with SIH based on orthostatic headache and diffuse pachymeningeal enhancement on brain MRI. One more month later, his headache was exacerbated, and brain CT showed diffuse SAH. Lumber puncture showed bloody CSF with a low CSF pressure of 20 mmH2O after a 30 ml intrathecal injection of saline. The patient was treated with a lumbar epidural blood patch and recovered. ② A 41-year-old male presented with orthostatic headache and nuchal pain. The brain CT scan confirmed the diagnosis of SAH. Brain MRI revealed diffuse dural thickening and bilateral frontoparietal subdural fluid collection. Lumber puncture showed bloody CSF with low CSF pressure. Then, an epidural blood patch was performed with satisfactory results.Conclusion: Dilation and rupture of intracranial venous structures might play significant roles in SIH combined with SAH. We should be alert to SIH patients who develop a new persistent severe headache without relief after lying down or a suddenly changed state of consciousness.

Procedural predictors of epidural blood patch efficacy in spontaneous intracranial hypotension

2019 ◽  
Vol 44 (2) ◽  
pp. 212-220 ◽  
Author(s):  
Gabriel L Pagani-Estévez ◽  
Jeremy K Cutsforth-Gregory ◽  
Jonathan M Morris ◽  
Bahram Mokri ◽  
David G Piepgras ◽  
...  
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Brain Mri ◽  
Spontaneous Intracranial Hypotension ◽  
Case Series ◽  
Mri Findings ◽  
Retrospective Case ◽  
Volume Number ◽  
Institutional Review ◽  
Blood Patch

Background and objectiveEpidural blood patch (EBP) is a safe and effective treatment for spontaneous intracranial hypotension (SIH), but clinical and procedural variables that predict EBP efficacy remain nebulous.MethodsThis study is an institutional review board-approved retrospective case series with dichotomized EBP efficacy defined at 3 months. The study included 202 patients receiving 604 EBPs; iatrogenic cerebrospinal fluid leaks were excluded.ResultsOf the EBPs, 473 (78%) were single-level, 349 (58%) lumbar, 75 (12%) bilevel, and 56 (9%) multilevel (≥3 levels). Higher volume (OR 1.64; p<0.0001), bilevel (3.17, 1.91–5.27; p<0.0001), and multilevel (117.3, 28.04–490.67; p<0.0001) EBP strategies predicted greater efficacy. Only volume (1.64, 1.47–1.87; p<0.0001) remained significant in multivariate analysis. Site-directed patches were more effective than non-targeted patches (8.35, 0.97–72.1; p=0.033). Lower thoracic plus lumbar was the most successful bilevel strategy, lasting for a median of 74 (3–187) days.ConclusionsIn this large cohort of EBP in SIH, volume, number of spinal levels injected, and site-directed strategies significantly correlated with greater likelihood of first EBP efficacy. Volume and leak site coverage likely explain the increased efficacy with bilevel and multilevel patches. In patients with cryptogenic leak site, and either moderate disability, negative prognostic brain MRI findings for successful EBP, or failed previous lumbar EBP, a low thoracic plus lumbar bilevel EBP strategy is recommended. Multilevel EBP incorporating transforaminal administration and fibrin glue should be considered in patients refractory to bilevel EBP. An algorithmic approach to treating SIH is proposed.

scholarly journals Early and Delayed Rebound Intracranial Hypertension Following Epidural Blood Patch in a Case of Spontaneous Intracranial Hypotension: A Case Report

2021 ◽  
Author(s):  
Elham Jafari ◽  
Maryam Karaminia ◽  
Mansoure Togha
Keyword(s):  
Intracranial Hypertension ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Secondary Headache ◽  
Inadequate Response ◽  
Blurred Vision ◽  
Blood Patch

Abstract Background: Spontaneous intracranial hypotension (SIH) is a secondary headache that has been attributed to a cerebrospinal fluid (CSF) leak. It may resolve spontaneously or require conservative treatment. An epidural blood patch (EBP) with autologous blood is performed in cases exhibiting an inadequate response to conservative methods. Rebound intracranial hypertension (RIH) can develop following an EBP in up to 27% of patients. It is characterized by a change in the headache features and is often accompanied by nausea, blurred vision. and diplopia. Symptoms commonly begin within the first 36 hours, but could develop over days to weeks. It is important to differentiate this rebound phenomenon from unimproved SIH, as the treatment options differ. Case presentation: Here we present an interesting case of a patient with SIH who was treated with EBP and developed both immediate RIH after 24 hours and delayed RIH 3 weeks following EBP. Conclusions: Following EBP for treatment of SIH, new onset of a headache having a different pattern and location should always be monitored for the occurrence of a RIH. A lumbar puncture should be done if the symptoms of elevated CSF pressure become intolerable or if the diagnosis is uncertain. Lack of early diagnosis and treatment and differentiation from SIH can cause complications and could affect the optic nerves.

scholarly journals Caudal Epidural Blood Patch for Spontaneous Intracranial Hypotension in a Patient Receiving Dual Antiplatelet Therapy

2020 ◽  
pp. 145-150
Author(s):  
Alan D. Kaye
Keyword(s):  
Antiplatelet Therapy ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Dual Antiplatelet Therapy ◽  
Symptom Relief ◽  
Spontaneous Intracranial Hypotension ◽  
Bleeding Risk ◽  
Csf Leak ◽  
Interlaminar Approach ◽  
Blood Patch

Background: Epidural blood patch (EBP) is routinely used to treat spontaneous intracranial hypotension (SIH). In the case of a patient receiving dual antiplatelet therapy, a caudal EBP was utilized for treatment of his SIH-related chronic headache as the traditional lumbar interlaminar approach was not advisable due to bleeding risk. While there are case reports supporting the efficacy of caudal EPB for treating SIH, none of the cases were performed in patients receiving antiplatelet therapy. In this case, we were uncertain whether antiplatelet agents would interfere with clot formation in the epidural space and preclude successful blood patch formation. Case Report: Herein, we present a 50-year-old man diagnosed with SIH after presenting with a 2-month history of intractable, orthostatic, bifrontal headache. He had undergone coronary stenting 37 days prior and was receiving dual antiplatelet therapy with aspirin and clopidogrel. After the patient failed conservative measures, he elected to proceed with caudal EBP. This provided only 2 hours of symptom relief. One week later, another EBP was performed, this time with complete resolution of the patient’s headache. Conclusion: Our case demonstrates that the caudal approach to EBP may be a safe and effective alternative to interlaminar blood patch for treatment of spontaneous intracranial hypotension in patients at increased bleeding risk related to antiplatelet therapy. Key words: Epidural blood patch, caudal blood patch, CSF leak, postural headache, SIH, spontaneous intracranial hypotension, anticoagulation

scholarly journals Cervicothoracic Epidural Blood Patch Provides Pain Relief after Failed Lumbar Epidural Blood Patch: A Case Report

2018 ◽  
pp. 205-207
Author(s):  
Antepreet Dua
Keyword(s):  
Case Report ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Single Case ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Academic Center ◽  
Blood Patch ◽  
Rigorous Study ◽  
Chronic Headaches

Background: Spontaneous intracranial hypotension is an increasingly relevant cause of headaches as the breadth and depth of its diagnosis and management improves. Objectives: The objective of this case report is to describe a novel treatment for headaches caused by spontaneous intracranial hypotension without locating the cerebrospinal fluid (CSF) leak and to review the diagnostic and therapeutic options for spontaneous intracranial hypotension. Study Design: This is a report of a single case. Setting: The setting for this case report is a major academic center. Methods: After a review of the treatments and interventions that our patient had previously undergone, we decided to trial epidural blood patches for her chronic headaches. Results: Although the exact site of a CSF leak could not be identified despite exhaustive diagnostic interventions, cervicothoracic epidural blood patches provided excellent pain control for our patient’s severe headaches. The patient was completely free of headaches for 15 hours and reported well-controlled pain for approximately a month after her procedure as well as after 5 subsequent monthly procedures. Limitations: As this is a report of a single case, more rigorous study in a larger patient population is needed to provide guidance. Conclusions: This case demonstrates that a nontargeted cervicothoracic epidural blood patch can be a treatment option for patients with spontaneous intracranial hypotension in which clinical suspicion is high despite nondiagnostic imaging. Key words: Spontaneous intracranial hypotension, cervicothoracic epidural blood patch, headache

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