scholarly journals Intracranial Hypotension Headache Caused by a Massive Cerebrospinal Fluid Leak Successfully Treated with a Targeted C2 Epidural Blood Patch: A Case Report

2013 ◽  
Vol 4;16 (4;7) ◽  
pp. 399-404
Author(s):  
Xiaobin Yi
Keyword(s):  
Cerebrospinal Fluid ◽  
Cervical Spine ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Steroid Injection ◽  
Epidural Steroid Injection ◽  
Csf Leak ◽  
Blood Patch ◽  
High Cervical ◽  
Epidural Steroid

Cervical epidural steroid injections, administered either intralaminarly or transforaminally, are common injection therapies used in many interventional pain management practices to treat cervicalgia or cervicobrachial pain secondary to spondylosis or intervertebral disc displacement of the cervical spine. Among the risks associated with these procedures are the risk for inadvertent dural puncture and the development of positional headache from intracranial hypotension. We report the case of a 31-year-old woman with a history of migraine and cervicalgia from cervical spine spondylosis and cervical disc degenerative disease that developed an intractable orthostatic headache accompanied by nausea and vomiting after a therapeutic high cervical intralaminar epidural steroid injection was administered directly to the C1-C2 spinal level. Although the initial magnetic resonance imaging of the brain was unremarkable, a computed tomography myelogram study revealed a massive cerebrospinal fluid (CSF) leak from the cervical spine. Repeated cervical epidural blood patches using a catheter targeted to the high cervical spine (C2) to inject 15 mL of autologous blood was required to totally alleviate her symptoms after she failed conservative therapy. Determining the optimal location or approach to administer an epidural blood patch can be a challenge depending on the location of the CSF leak. Our case demonstrates that targeted cervical epidural blood patch placement using an easily manipulated catheter under fluoroscopic guidance is a safe and effective approach to treat a massive CSF leak in the high cervical spine region caused by prior therapeutic cervical spine epidural steroid injection. Key words: Cervical epidural blood patch, intracranial hypotension, intracranial hypotension headache, spinal headache, orthostatic headache, epidural steroid injection, cerebrospinal fluid leak, post dural headache

scholarly journals Spontaneous C1-2 Cerebrospinal Fluid Leak Treated with a Targeted Cervical Epidural Blood Patch Using a Cervical Epidural Racz Catheter

2014 ◽  
Vol 3;17 (3;5) ◽  
pp. E381-E384
Author(s):  
Dr. Yong-Shin Kim
Keyword(s):  
Cerebrospinal Fluid ◽  
Cervical Spine ◽  
Magnetic Resonance ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Cerebrospinal Fluid Leakage ◽  
Blood Patch ◽  
Associated Symptoms ◽  
Occipital Headache

A 39-year-old woman with no history of trauma or meningitis presented to the neurology department of our hospital with an occipital headache, neck pain, nausea, and dizziness that had worsened during the previous month. The headache worsened when sitting or standing and partially regressed when lying down. She was diagnosed with spontaneous intracranial hypotension (SIH) and received conservative management. After failing to respond to conservative management, she underwent an autologous epidural blood patch (EBP) at the T7-8 level. The headache and associated symptoms did not improve after the procedure. Magnetic resonance (MR) myelography suggested a cerebrospinal fluid leakage at the C1-2 level resulting in intracranial hypotension. An 18-gauge Tuohy needle was inserted at the T1-2 interlaminal level using a paramedian approach under fluoroscopic guidance. The cervical epidural Racz catheter was threaded through the Tuohy needle up to the cervical spine and the catheter tip was confirmed to be at the right cervical 1-2 site on an anteroposterior (AP) view. Five mL of autologous blood was injected into the epidural space through the cervical epidural Racz catheter. Her occipital headache and associated symptoms gradually disappeared after the procedure. Seven days later the headache was largely resolved and she was discharged. Follow-up magnetic resonance imaging (MRI) showed the disappearance of abnormal radiological features associated with intracranial hypotension. She currently remains symptom free for 9 months. Delivery of autologous blood patch via a cervical epidural Racz catheter inserted from the upper thoracic spine can be a safe and effective method for patients with SIH due to cerebrospinal fluid (CSF) leakage in the upper cervical spine. Key words: Cerebrospinal fluid leakage, epidural blood patch, intracranial hypotension, myelography, occipital headache

scholarly journals Timing of Neuraxial Pain Interventions Following Blood Patch for Post Dural Puncture Headache

2014 ◽  
Vol 2;17 (2;3) ◽  
pp. 119-125
Author(s):  
Karina Gritsenko
Keyword(s):  
Health Care Professionals ◽  
Time Course ◽  
Dural Puncture ◽  
Epidural Blood Patch ◽  
Steroid Injection ◽  
The Body ◽  
Epidural Steroid Injection ◽  
Post Dural Puncture Headache ◽  
Blood Patch ◽  
Epidural Steroid

Post dural puncture headache (PDPH) is a common complication of interventional neuraxial procedures. Larger needle gauge, younger patients, low body mass index, women (especially pregnant women), and “traumatic” needle types are all associated with a higher incidence of PDPH. Currently, an epidural blood patch is the gold-standard treatment for this complication. However, despite the high PDPH cure rate through the use of this therapy, little is known about the physiology behind the success of the epidural blood patch, specifically, the time course of patch formation within the epidural space or how long it takes for the blood patch volume to be resorbed by the body. Of the many unanswered and debated topics related to PDPH and epidural blood patches, one additional specific question that may alter clinical management is when it is safe for patients who have experienced a disruption of the thecal space and have undergone this procedure to have a subsequent epidural or spinal procedure, such as a neuraxial anesthetic (i.e. a spinal anesthetic for an elective outpatient procedure) or an interventional pain procedure for chronic pain management. This question becomes more unclear if the new procedure includes a steroid medication. As an example, an older patient presents with a history of lumbar disc disease and during lumbar epidural steroid injection, an inadvertent wet tap occurs leading to PDPH. Following management with fluids, caffeine, medications, and a successful epidural blood patch, it remains unclear as to when would be the best time frame to consider a second lumbar epidural steroid injection. We identified the 3 main risk factors of subsequent interventional neuraxial procedures as (1) disruption of the epidural blood patch and ongoing reparative processes, (2) epidural procedure failure, and (3) infection. We looked at the literature, and summarized the existing literature in order to enable health care professionals to understand the time course of dural repair as well as the risks of subsequent neuraxial procedures after epidural blood patches. This review poses the question using an evidence based review to discuss the appropriate time course to proceed. Key words: Post dural puncture headache, epidural steroid injection, wet tap, timing of therapy

scholarly journals Spontaneous spinal cerebrospinal fluid leaks: a review

2000 ◽  
Vol 9 (1) ◽  
pp. 1-9 ◽  
Author(s):  
Wouter I. Schievink
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Traumatic Event ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Neck Stiffness ◽  
Arm Pain ◽  
Cranial Nerve Dysfunction ◽  
Blood Patch

Spontaneous intracranial hypotension has become a well-recognized clinical entity, but it remains an uncommonly, and probably underdiagnosed, cause of headache; its estimated prevalence is only one in 50,000 individuals. The clinical spectrum of spontaneous intracranial hypotension is quite variable and includes headache, neck stiffness, cranial nerve dysfunction, radicular arm pain, and symptoms of diencephalic or hindbrain herniation. Leakage of the spinal cerebrospinal fluid (CSF) is the most common cause of spontaneous intracranial hypotension. A combination of an underlying weakness of the spinal meninges and a more or less trivial traumatic event is often found to cause this event in these patients. Typical magnetic resonance imaging findings include diffuse pachymeningeal enhancement, sub-dural fluid collections, and downward displacement of the brain, sometimes mimicking a Chiari I malformation. Opening pressure is often, but not always, low, and examination of CSF may reveal pleocytosis, an elevated protein count, and xanthochromia. The use of myelography computerized tomography scanning is the most reliable method for the accurate localization of the CSF leak. Most CSF leaks are found at the cervicothoracic junction or in the thoracic spine. The initial treatment of choice is a lumbar epidural blood patch, regardless of the location of the CSF leak. If the epidural blood patch fails, the blood patch procedure can be repeated at the lumbar level, or a blood patch can be directed at the exact site of the leak. Surgical repair of the CSF leak is safe and generally successful, although a distinct structural cause of the leak often is not found.

scholarly journals Spontaneous C1-2 CSF Leak Treated with High Cervical Epidural Blood Patch

2008 ◽  
Vol 35 (1) ◽  
pp. 102-105 ◽  
Author(s):  
Philip WH Peng ◽  
Richard Farb
Keyword(s):  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Memory Loss ◽  
Csf Leak ◽  
Cerebellar Tonsil ◽  
Iodinated Contrast ◽  
Blood Patch ◽  
Magnetic Resonance Imaging Mri ◽  
Fluid Collections ◽  
High Cervical

Spontaneous intracranial hypotension (SIH) is a condition caused by spontaneous spinal cerebrospinal fluid (CSF) leaks. Clinically, it is characterized by orthostatic headache and may respond well to epidural blood patch. Other neurological presentations of SIH include diplopia, memory loss, hearing deficits, Parkinsonism, ataxia, obtundation and even coma.Magnetic resonance imaging (MRI) is crucial in the diagnosis of this condition. Typical radiological features include diffuse pachymeningeal enhancement, descent of the cerebellar tonsil, a decrease in the size of prepontine and perichiasmatic cisterns, and subdural fluid collections. However, radiological imaging such as radionuclide cisternography or spinal MRI are not reliable in detecting the site of leakage. Myelography with iodinated contrast followed by thin-cut computed tomography (CT) or MRI of the entire spine has been shown as the technique of choice in defining the location of the CSF leak.

Multiple Fibrin Glue Use in a Complicated Case of Postdural Puncture Headache Following Intrathecal Drug Delivery System Placement: A Case Report

2019 ◽  
pp. 77-81
Author(s):  
Matthew Chung
Keyword(s):  
Drug Delivery ◽  
Cerebrospinal Fluid ◽  
Drug Delivery System ◽  
Fibrin Glue ◽  
Delivery System ◽  
Epidural Blood Patch ◽  
Csf Leak ◽  
Postdural Puncture Headache ◽  
Intrathecal Drug Delivery ◽  
Blood Patch

A postdural puncture headache (PDPH) is a well-described complication after implantation of an intrathecal drug delivery system (IDDS). Treatment is typically with supportive management with the occasional need for an epidural blood patch. We describe a case of a patient with refractory muscle spasticity secondary to cerebral palsy that required a baclofen IDDS implantation and subsequently developed a PDPH. After failing conservative therapy as well as an epidural blood patch, the decision was made to attempt an epidural fibrin patch, which transiently improved her headache. Upon return of the patient’s symptoms, computed tomography myelogram demonstrated an extensive cerebrospinal fluid leak with ventral spread into the retroperitoneal space. Using a novel technique, a second epidural fibrin glue patch was administered just adjacent to the IDDS catheter insertion point, which was then successful in resolving her symptoms. Key words: Intrathecal drug delivery system, postdural puncture headache, dural tear, cerebrospinal fluid (CSF) leak, fibrin glue, epidural blood patch

scholarly journals Sinus Thrombosis in a Patient with Intracranial Hypotension: A Suggested Hypothesis of Venous Stasis

2011 ◽  
Vol 17 (2) ◽  
pp. 248-251 ◽  
Author(s):  
K-W. Yoon ◽  
M-K. Cho ◽  
Y.J. Kim ◽  
C.S. Cho ◽  
S-K. Lee
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Rare Case ◽  
Sinus Thrombosis ◽  
Fluid Collection ◽  
Csf Leak ◽  
Venous Stasis ◽  
Sagittal Sinus ◽  
Blood Patch ◽  
Spine Mri

We describe the case of a 26-year-old man with orthostatic headache. Cerebral angiography revealed thrombosis in the sagittal sinus. Spine MRI showed cerebrospinal fluid collection at the C1–2 level. We performed blood patch and the symptoms disappeared. We report a rare case of intracranial hypotension caused by CSF leak and describe our hypothesis that SIH can change the velocity of cerebral blood flow and cause thrombosis.

Dural puncture during lumbar epidural access in the setting of degenerative spondylolisthesis: case series and risk mitigation strategies

2021 ◽  
pp. rapm-2021-102963
Author(s):  
Vivek Sindhi ◽  
Christine G Lim ◽  
Anver Khan ◽  
Carlos Pino ◽  
Steven P Cohen
Keyword(s):  
Dural Puncture ◽  
Steroid Injection ◽  
Risk Mitigation ◽  
Degenerative Spondylolisthesis ◽  
Epidural Steroid Injection ◽  
Mitigation Strategies ◽  
Epidural Needle ◽  
Blood Patch ◽  
Risk Mitigation Strategies ◽  
Epidural Steroid

Degenerative spondylolisthesis is a common back pathology in the general adult population. Patients with this condition may present for epidural steroid injection, epidural blood patch, or epidural analgesia. We report five patients with degenerative spondylolisthesis who experienced inadvertent dural puncture during interlaminar epidural steroid injection attempts: four with intrathecal contrast spread or cerebrospinal backflow into the epidural needle and one with subdural contrast spread. Patients with degenerative spondylolisthesis may be at higher risk for dural puncture due to stretching of the dura and contraction of the epidural space at the translated spinal level. In the following report, we summarize the cases and suggest risk mitigation strategies for both chronic and acute pain physicians.

scholarly journals Fever following an Epidural Blood Patch in a Child

2012 ◽  
Vol 2012 ◽  
pp. 1-4 ◽  
Author(s):  
Agnes I. Hunyady ◽  
Corrie T. M. Anderson ◽  
John D. Kuratani ◽  
Anjana Kundu
Keyword(s):  
Fluid Dynamics ◽  
Cerebrospinal Fluid ◽  
Safety Profile ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Pediatric Population ◽  
Fluid Pressure ◽  
Cerebrospinal Fluid Pressure ◽  
Cerebrospinal Fluid Dynamics ◽  
Blood Patch

There is increasing evidence that children suffer from the consequences of spontaneous or iatrogenic intracranial hypotension. Pediatric epidural blood patch is gaining popularity because of its ability to alter cerebrospinal fluid dynamics and to alleviate headaches attributed to low cerebrospinal fluid pressure. There is, however, still not enough data to document the safety profile of an epidural blood patch. Here we describe a case of a fever in a child temporally related to the administration of an epidural blood patch. This case depicts the dilemmas in making the diagnosis and instituting treatment for complications of this procedure in the pediatric population.

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.

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