Thoracic epidural blood patch for spontaneous intracranial hypotension: case report and review of the literature.

Abstract

Spontaneous intracranial hypotension (SIH) is caused by spinal leakage of cerebrospinal fluid (CSF). Treatment is directed at sealing the site of leak, which is often difficult to localize. We present a case of near fatal SIH that was treated with thoracic epidural blood patching. A 47-yearold male presented with orthostatic headache and bilateral cranial nerve VI palsies progressing over several weeks. Brain magnetic resonance (MR) imaging showed features typical of SIH and identified an epidural collection stretching from spinal levels C6 to T4, but further imaging with MR myelography and radionuclide cisternography failed to identify a precise site of leak. The patient worsened in the hospital requiring craniotomy for evacuation of an evolving subdural hematoma (SDH). Epidural blood patch was performed at the T1-2 level, the presumed location of the leak due to presence of a bone spur on computed tomography and the large corresponding CSF collection. This quickly led to resolution of the headache and cranial nerve palsies, and later to the complete resolution of his SDH. Through this case and review of the literature, we aim to demonstrate that directed cervical or thoracic blood patching should be considered for SIH as an alternative to the conventional lumbar blood patch. KEywoRds: Epidural blood patch, Intracranial hypotension, Thoracic ÖZSpontan intrakraniyal hipotansiyonun (SIH) nedeni beyin omurilik sıvısının (BOS) spinal sızıntısıdır. Tedavi, sızıntı bölgesinin kapatılmasını hedefler ama bu bölgenin bulunması genellikle zordur. Torasik epidural kan yaması konmasıyla tedavi edilen neredeyse ölümcül bir SIH olgusu sunuyoruz. 47 yaşında bir erkek hasta birkaç haftadır ilerleyen ortostatik başağrısı ve bilateral VI. kraniyal sinir paralizisiyle geldi. Beyin manyetik rezonans (MR) görüntülemesi SIH için tipik özellikler gösterdi ve spinal C6 ila T4 seviyeleri arasında bir epidural sıvı toplanmasına işaret etti ama MR miyelografi ve radyonüklid sisternografi ile yapılan ek incelemeler tam olarak sızıntı yerini gösteremedi. Hastanın durumu hastanede kötüleşti ve giderek büyüyen bir subdural hematomun (SDH) boşaltılması için kraniyotomi gerekti. Bilgisayarlı tomografide bir kemik çıkıntısı bulunduğundan ve karşılık gelen büyük bir BOS birikimi olduğundan sızıntının varsayılan konumu olan T1-2 seviyesine epidural kan yaması uygulandı. Bunun sonucunda başağrısı ve kraniyal sinir paralizileri hızla iyileşti ve sonrasında SDH tamamen geçti. Bu olgu ve literatür derlemesi yoluyla servikal ve torasik kan yaması yerleştirmenin SIH durumunda konvansiyonel lumber kan yaması yerleştirmeye bir alternatif olarak düşünülmesi gerektiğini belirtiyoruz.

A case report of intracranial hemorrhage after spinal anesthesia

“…In the present case, epidural blood patch was administered for the treatment of CSDH. Various treatments for CSDH after PDPH have been reported including observation, surgical resection of the hematoma, epidural blood patch, or both surgical resection and epidural blood patch [ 7 , 8 , 18 , 19 ]. The treatment plan is decided according to the patient’s neurological symptoms and the size of the hematoma.…”

Treatment of cerebrospinal fluid leak after spine surgery

“…The EBP can not only seal the CSF leak, but also increase the epidural fluid pressure to reverse the CSF blood gradient along the entire spinal cord 3, 5, 6, 25. For patients with an uncertain site of CSF leak, lumbar EBP should be used.…”

MRI myelography for diagnosis and targeted blood patching of multilevel thoracic spine CSF leaks: Report of 2 cases

“…The standard volume used in lumbar blood patching is approximately 20-25 mL to achieve a tamponade effect [13], [14]. Studies have also described using MRI to diagnosis and monitoring smaller volume 3-18 mL direct blood patching of cervical and/or thoracic leak sites [15], [16], [17]. Wu et al found that first epidural blood patch response rates were higher for anterior epidural fluid collections of <8 segments, targeted blood patching, and injected blood volume ≥22.5 mL [18].…”