Treating Spontaneous Intracranial Hypotension with an Anesthetic Modality: The Role of the Epidural Blood Patch

Abstract

Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic and therapeutic challenge; it can present with a broad clinical spectrum of symptoms, can lead to SDH and, if conservative treatment fails, an epidural blood patch (EBP) is a viable treatment option. Although the exact etiology of SIH is not known, it is believed to be due to cerebrospinal fluid (CSF) leak or a low CSF pressure. Case Series: Three patients (two males and one female) with ages ranging between 38 and 53 years old who presented with complaints of not only an orthostatic headache, but also a variety of symptoms of SIH, including the formation of two SDHs in one of them, were included in this series. These patients did not respond to conservative management and, subsequently, given the clinical and radiological evidence of SIH, were referred to the Anesthesiology Department for an EBP. Diagnostic workup was facilitated by imaging modalities, including magnetic resonance imaging (MRI) of the brain and spinal cord, prior to the EBP. All three patients were subjected to an EBP with an 18-gauge epidural needle. A total of between 30 and 43 mL of autologous blood was collected from the patients and was injected into the epidural space under strict aseptic conditions. Two lumbar (L1–L2, L2–L3) EBPs and one thoracic (T11–T12) EBP were performed on the three patients, respectively. All patients reported complete resolution of symptoms following the EBPs, while MRI improved substantially. Conclusions: This report describes three cases of SIH with CSF leak originating from the cervical, the thoracic and the lumbar level. The EBP restored CSF pressure and relieved the patients’ persistent symptoms. MRI helps in revealing indirect signs of a low volume of CSF, though it may not be possible to locate the actual site of the leak. In conclusion, EBP is a well-accepted and beneficial treatment modality for SIH when conventional measures fail.

A Low-Volume Epidural Blood Patch for the Treatment of Spontaneous Intracranial Hypotension: A Case Report

“…Immediate tamponade effect from the injected blood causes compression of the thecal space with a quick increase of lumbar and consequently intracranial CSF pressure. Long-lasting effect by the plugging of the dura opening with the creation of a blood clot caused by the interaction between the injected blood and procoagulant components in the leaking CSF [ 15 ]. Perthen et al analyzed the treatment of 73 patients with SIH.…”

Spontaneous Intracranial Hypotension: Case Report and Update on Diagnosis and Treatment

“…It is usually performed with 10-50 mL autologous blood [5,25] and acts immediately via volume replacement. The long-lasting effect of sealing the leak is due to the interaction between the blood and pro-coagulant components in the leaking CSF, leading to the formation of a clot [5,59].…”

Caffeine for Headaches: Helpful or Harmful? A Brief Review of the Literature

“…Firstly, caffeine inhibits phosphodiesterase and antagonizes adenosine, leading to cerebral vasoconstriction; secondly, it increases the production of cerebral fluid by activating the sodium–potassium pump. If symptoms do not respond to medical treatment, an epidural blood patch (EBP) may be considered [ 68 ]. In a meta-analysis of studies by D’Anton et al, conservative treatment was effective in 28% of patients.…”