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 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.

Spontaneous Intracranial Hypotension Treated with CT-guided Cervical Epidural Blood Patch - A case report -

2007 ◽  
Vol 52 (1) ◽  
pp. 115 ◽  
Author(s):  
Jin Hye Min ◽  
Young Soon Choi ◽  
Yong Ho Kim ◽  
Woo Kyung Lee ◽  
Yong Kyung Lee ◽  
...  
Keyword(s):  
Case Report ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Ct Guided ◽  
Blood Patch

scholarly journals Intracranial Hypotension for Anesthesiologists: What We Should Know

2019 ◽  
pp. 69-76
Author(s):  
Maria Eugenia Calvo
Keyword(s):  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Case Series ◽  
Low Flow ◽  
Csf Leak ◽  
Common Denominator ◽  
Invasive Treatment ◽  
Blood Patch ◽  
Mechanism Of Trauma ◽  
Csf Leaks

The common denominator of spontaneous intracranial hypotension (SIH), postsurgical cerebral spinal fluid (CSF) leaks, and postpuncture headache (PPH) is a decrease in CSF volume. The typical presentation is orthostatic headaches, but atypical headaches can be difficult to diagnose and challenging to treat. Management is based on clinical suspicion and characterization of the headache, followed by imaging (noninvasive or invasive). Treatment ranges from conservative to different modalities of epidural blood patches, fibrin glue injections, or surgical exploration and repair. We report 5 cases with great variation in clinical and radiological presentations. Two cases of SIH involved difficult diagnosis and treatment, 2 others featured postsurgical high-flow CSF leaks, and one case presented with a low-flow CSF leak that needed closer evaluation in relation to hardware manipulation. In all cases, recommendations for diagnosis and management of intracranial hypotension were followed, even though in 3 cases the mechanism of trauma was not related to spontaneous hypotension. All cases of headache were resolved. The actual recommendations for SIH are very effective for PPH and postsurgical CSF leaks. With this case series, we illustrate how anatomical and clinical considerations are paramount in choosing appropriate imaging modalities and clinical management. Key words: CSF leak, epidural blood patch, intracranial hypotension, postural headaches, subdural hematomas

Severe acute orthostatic headache: spontaneous intracranial hypotension (SIH)

2021 ◽  
Vol 14 (6) ◽  
pp. e243179
Author(s):  
Pushpendra Nath Renjen ◽  
Dinesh Mohan Chaudhari ◽  
Nidhi Goyal ◽  
Kamal Ahmed
Keyword(s):  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Signs And Symptoms ◽  
Csf Leak ◽  
Lumbosacral Spine ◽  
Ct Guided ◽  
Mri Features ◽  
Blood Patch ◽  
Csf Leakage ◽  
Underlying Mechanisms

The most common cause of spontaneous intracranial hypotension headache is a cerebrospinal fluid (CSF) leakage, but the underlying mechanisms remain unknown. Intracranial hypotension is characterised by diffuse pachymeningeal enhancement on cranial MRI features, low CSF pressure and orthostatic headaches mostly caused by the dural puncture. We report a 31-year-old woman who presented to our services with reports of continuous severe bifrontal headache, which increased on sitting up and resolved on lying down. MRI of the cervical and lumbosacral spine showed signs of CSF leak; hence, patient was diagnosed with spontaneous intracranial hypotension headache. A CT-guided epidural blood patch was done at L4–5 with fibrin glue injected at the site of leak. The patient’s signs and symptoms improved after the procedure.

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.

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 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

Use of confirmatory imaging studies to illustrate adequate treatment of cerebrospinal fluid leak in spontaneous intracranial hypotension

2010 ◽  
Vol 113 (5) ◽  
pp. 955-960 ◽  
Author(s):  
Timothy W. Vogel ◽  
Brian J. Dlouhy ◽  
Matthew A. Howard
Keyword(s):  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Cerebrospinal Fluid Leak ◽  
Neurosurgical Procedures ◽  
Adequate Treatment ◽  
Blood Patch ◽  
Patients At Risk ◽  
Fluid Leak ◽  
Csf Leaks

Spontaneous intracranial hypotension (SIH) is a syndrome with serious neurological sequelae. As demonstrated by the following report, recurrent episodes of SIH can be difficult to diagnose when associated with other neurosurgical procedures, such as craniectomies. In this paper, the authors demonstrate SIH presenting as a subdural hematoma with recurrence of CSF leaks. Spontaneous intracranial hypotension was further complicated by paradoxical herniation following a craniectomy. Treatment of SIH necessitated multiple epidural blood patches for CSF leaks at different spinal levels and at different times. The efficacy of each epidural blood patch was confirmed with radionuclide imaging. Confirmation of effective blood patch placement may be useful for identifying patients at risk for a failed epidural blood patch or for patients whose neurological examination results have not fully improved.

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