Fluoroscopically guided epidural blood patch with subsequent spinal CT scans in the treatment of spontaneous cerebrospinal fluid hypovolemia

Watanabe, Keisuke; Hashizume, Kazuyoshi; Kawaguchi, Masahiko; Fujiwara, Aki; Sasaoka, Noriyuki; Furuya, Hitoshi

doi:10.3171/2011.1.jns101326

Cited by 22 publications

(17 citation statements)

References 22 publications

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“…To the best of our knowledge, the detailed analysis of CT myelography, which is less invasive and can be performed easily on a routine basis, has yet to be described in the literature. 2,8,[16][17][18] The study reported here raises the following 4 points with regard to the diagnosis and treatment of spontaneous CSF leaks. First, EBP at the level near the spinal lesions resulted in good outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…Although the use of targeted EBP is increasingly being reported, previous studies have not described in detail how to determine the leak site and target the spinal level for EBP. 8,[16][17][18] A common cause of CSF leaks is considered to be a ventral dural defect or meningeal diverticulum at the dural root sleeves. 3 In terms of leakage detection, the diagnostic method with the highest sensitivity is CT myelography.…”

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confidence: 99%

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Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Yoshida¹,

Takai²,

Taniguchi³

2014

SPI

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Object The purpose of this study was to describe significant CT myelography findings for determination of the leak site and outcome of targeted epidural blood patch (EBP) in patients with spontaneous CSF leaks. Methods During 2005–2013, spontaneous CSF leaks were diagnosed for 12 patients with orthostatic headaches. The patients received targeted EBP on the basis of CT myelography assessments. Results Computed tomography myelograms revealed ventral extradural collection of contrast medium distributed over multiple spinal levels (average 16 levels). Intraforaminal contrast medium extravasations were observed at multiple spinal levels (average 8.2 levels). For 8 (67%) of 12 patients, spinal lesions were noted around the thecal sac and included calcified discs with osteophytes, an ossified posterior longitudinal ligament, and an ossified yellow ligament; lesions were mostly located ventral to the thecal sac and were in close contact with the dura mater. The levels of these spinal lesions were considered potential leak sites and were targeted for EBP. For the remaining 4 patients who did not have definite spinal lesions around the thecal sac, leak site determination was based primarily on the contrast gradient hypothesis. The authors hypothesized that the concentration of extradural contrast medium would be the greatest and the same as that of intradural contrast medium at the leak site but that it would decrease with increased distance from the leak site according to the contrast gradient. Epidural blood patch was placed at the level of spinal lesions and/or of the greatest and same concentration of contrast medium between the intradural and extradural spaces. For 10 of the 12 patients, the orthostatic headaches decreased significantly within a week of EBP and disappeared within a month. For the remaining 2 patients, headaches persisted and medical treatment was required for several months. For 3 patients, thick chronic subdural hematomas caused severe headaches and/or disturbed consciousness because of the mass effect of the hematomas, which were removed by bur hole drainage surgery. For 1 patient, bur hole drainage before EBP on the day of admission to hospital resulted in subdural tension pneumocephalus. The patient's headache immediately disappeared after EBP, and the hematoma did not recur. The other 2 patients underwent EBP followed by bur hole drainage, which resulted in improvements and disappearance of the hematomas. Over the follow-up period (mean 39 months), no CSF leaks or chronic subdural hematomas had recurred in any patient after EBP; by the final follow-up visit, all patients had returned to their jobs. Conclusions The most significant finding of this study was that spinal ventral calcified or ossified lesions, which may be associated with a dural tear, were present in approximately 70% of patients. Targeted EBP to these lesions resulted in good outcomes.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Yoshida¹,

Takai²,

Taniguchi³

2014

SPI

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“…[3][4][5][6][7][8][9][10] Thus, only a few reports of targeted EBPs exist in the literature. [11][12][13][14][15] In contrast to a blind EBP, a targeted EBP relies on an accurate localization of the leakage site. To this end, several imaging techniques are available, including CT myelography, radioisotope cisternography, and MR imaging of the spine.…”

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confidence: 99%

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

Wendl¹,

Schambach²,

Zimmer³

et al. 2011

AJNR Am J Neuroradiol

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SUMMARY:Intracranial hypotension is a rare cause of persistent headache mostly originating from a dural CSF leak. If a conservative treatment fails, a minimally invasive EBP can lead to a successful sealing of such a leak. Independent of the leakage site, an EBP is usually applied at the lumbar level with varying success. We used CT myelography to detect the site of the dural leakage, then immediately applied a targeted EBP at the corresponding level to patch the leak. Seven patients from our clinic were treated with a single targeted EBP in the lumbar or cervical spine. Within 24 hours, 6 patients experienced a considerable relief of symptoms; 1 patient went into remission after a repeat procedure. Our preliminary data suggest that a CT-guided, CT myelography-assisted targeted EBP is a safe and effective treatment for persistent spinal CSF leaks.ABBREVIATIONS: EBP ϭ epidural blood patch; IHS ϭ intracranial hypotension syndrome; LP ϭ lumbar puncture; SDH ϭ subdural hematoma I HS usually manifests with symptoms including orthostatic headache, nausea, neck pain, vomiting, and dizziness. In most cases, a persistent CSF leak is the cause of IHS. Such a persistent dural leak may sometimes arise spontaneously due to a rupture of subarachnoid perineural cysts. 1 However, it occurs most commonly as an undesirable effect of a lumbar puncture or is related to trauma or spinal surgery. 2 Patients frequently recover spontaneously; therefore, the first approach should be conservative treatment including bed rest, analgesic medication, and oral hydration to restore the depleted CSF volume. If the conservative treatment fails, an EBP should be considered as a minimally invasive therapy option before taking surgical intervention into account. In general, the EBP itself can be performed either blindly at the lumbar level, or it may be targeted at the suspected leakage site. Most studies, however, arrive at the conclusion that a blind lumbar EBP is preferred due to an assumed lower risk, though a targeted EBP appears to be more effective. 3-10 Thus, only a few reports of targeted EBPs exist in the literature. [11][12][13][14][15] In contrast to a blind EBP, a targeted EBP relies on an accurate localization of the leakage site. To this end, several imaging techniques are available, including CT myelography, radioisotope cisternography, and MR imaging of the spine. However, even if the site of the leak is known precisely, the execution of the CT-guided targeted patch is difficult due to the limited anatomic resolution of the planning CT scan for intra-and extradural compartments.In view of these problems, we performed CT myelography in a group of 7 patients with IHS and proved epidural CSF leak. We then used the resultant contrast-enhanced images to plan, and also guide, the targeted EBPs. Materials and MethodsAfter giving informed consent, all patients underwent a CT myelography with subsequently guided autologous epidural blood patches at the site of the leak. The myelography consisted of an injection of 15 mL of contrast agent (...

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“…9 Prior authors have reported symptomatic improvement rates ranging from 50% to 100% with site-directed epidural blood/fibrin patch procedures by using CT or fluoroscopic guidance. [10][11][12][13][14][15] These treatment options, however, often require epidural punctures in the upper thoracic and cervical spine. Epidural puncture in these regions is technically more challenging due the anatomy and the epidural space becoming smaller as you ascend from the lumbar to the cervical region.…”

Section: Discussionmentioning

confidence: 99%

Large-Volume Blood Patch to Multiple Sites in the Epidural Space through a Single-Catheter Access Site for Treatment of Spontaneous Intracranial Hypotension

Griauzde¹,

Gemmete

Chaudhary³

et al. 2014

American Journal of Neuroradiology

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Fluoroscopically guided epidural blood patch with subsequent spinal CT scans in the treatment of spontaneous cerebrospinal fluid hypovolemia

Abstract: The results indicated that fluoroscopically guided EBP and subsequent spinal CT scans may provide a highly effective therapy in patients with SCH proven on CT myelography studies.

Cited by 22 publications

References 22 publications

Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

Large-Volume Blood Patch to Multiple Sites in the Epidural Space through a Single-Catheter Access Site for Treatment of Spontaneous Intracranial Hypotension

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