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 (...