Spontaneous Intracranial Hypotension and the durability of Epidural 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.

Cervical epidural blood patch in spontaneous intracranial hypotension: A case report

“…Repeat blood patch may be needed in case of failed treatment with the first blood Patch [2,9,19,28,29]. The anatomical epidural space becomes smaller as we ascend from the lumbar to the cervical region [15].…”

“…Any changes in these processes leads to altered CSF pressure causing various neurological symptoms, most common of which is an orthostatic headache [1]. However patients may also present with focal neurological deficits or altered mentation [2]. Spontaneous Intracranial Hypotension (SIH) is an unusual cause of orthostatic headache in young and middle-aged individuals [3].…”

“…Uncomplicated mild to moderate headaches may initially be treated conservatively with bed rest, hydration, caffeine and abdominal binders [14]. Mainstay of interventional therapy is Epidural Blood Patch (EBP) [2]. Repeat epidural blood patch may be considered using a higher volume after 5 days [3].…”

“…In one study, epidural blood patch done via fluoroscopy at the lumbar level completely resolved symptoms in 85% of patients with postdural puncture headaches [17]. Another study reported relief of headache with EBP in 52% patients whereas 22% required a second EBP for relief of symptoms [2]. However, cervical epidural blood patch is uncommon due to the fear of neurological complications such as spinal cord compression [9].…”