Clinical effect of the proximity of epidural blood patch injection to the leakage site in spontaneous intracranial hypotension

Lee, Jin Young; Lee, Mi Ji; Park, Hue Jung; Park, Jin Hyoung; Jeong, Heejoon; Oh, Min-Seok; Son, Yong Hun; Sim, Woo Seog

doi:10.1080/02688697.2018.1519109

Cited by 13 publications

(7 citation statements)

References 24 publications

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“…With regard to other authors, we fully agree that using the contrast agent allows to visualize the administration site. [ 5 , 9 , 14 , 23 ] It is also our believe that the use of contrast is reasonable for sealing techniques with epidural administration into the spinal canal. However, in our opinion, the use of contrast agents is not essential in the technique of sealing throughout intravertebral foramen under the guidance of CT, because these techniques provide excellent efficacy of the correct needle location, for example, in the intervertebral foramen below the nerve root.…”

Section: Discussionmentioning

confidence: 86%

Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension

Ząbek

2022

Surgical Neurology International

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Background: Spontaneous intracranial hypotension (SIH) is a rare disease characterized by a decrease in the volume and pressure of cerebrospinal fluid (CSF) resulting from its leakage through the dura mater. SIH is curable, but it can lead to serious clinical sequelae or even death if not treated properly. Case Description: A 37-year-old female with headaches occurring in standing position and increasing especially during verticalization. Magnetic resonance imaging showed an image characteristic of SIH. Conservative treatment was applied in the form of bed rest. CT myelography scan located the site of CSF leakage. As the conservative treatment proved inefficient, it was decided to perform an epidural fistula sealing using the patient’s venous blood, administered under computed tomography guidance. The performed procedure completely resolved the patient’s complaints, allowing her to be discharged home. Conclusion: Patients with suspected SIH should remain in the supine position until a definitive diagnosis is made. Sealing the meningeal fistula with venous blood under computed tomography guidance should be considered in case of conservative treatment failure.

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Section: Discussionmentioning

confidence: 86%

Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension

Ząbek

2022

Surgical Neurology International

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“…There is no consensus on whether the epidural blood patch must be placed precisely over the site of the spinal CSF leak, or whether, alternatively, it might suffice to raise the pressure in the epidural space with a non-targeted patch application (31,(36)(37)(38). Punctures at multiple lumbar levels may be needed to deliver the epidural blood to the site of the leak; the technique involves demonstration of an uninterrupted flow of contrast medium (and thus, presumably, of the subsequently injected blood as well) epidurally in the cranial direction.…”

Section: Discussionmentioning

confidence: 99%

“…If the symptoms fail to improve, an epidural blood patch (or fibrin-glue patch) is applied. An epidural blood patch can be applied without any imaging with the aid of the loss-of-resistance method-the administering physician detects penetration into the epidural space as a loss of resistance to passage of the needle right after the tip has crossed the ligamentum flavum-or else under fluoroscopic or CT guidance, often after prior CT myelography (Figures 2a, 3) (31,32).…”

Section: Treatmentmentioning

confidence: 99%

Spontaneous Intracranial Hypotension

Urbach

Fung

Dovi-Akué

et al. 2020

Deutsches Ärzteblatt International

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pontaneous intracranial hypotension was first described in 1938 by Georges Schaltenbrand, a neurologist in Würzburg, Germany, who named it "hypoliquorrhea" (1, 2). Isolated case reports appeared in the 1940s, and the syndrome has been described many times in print since the mid-1990s (3-9).* Schievink et al. carried out an observational study in the greater Los Angeles area to determine the incidence of SIH. 11 patients with SIH and 23 with spontaneous subarachnoid hemorrhage (SAH) were seen in an emergency department (10, 11). On the basis of an assumed incidence of 10 cases of SAH per 100 000 persons per year, an annual incidence of 5 SIH cases per 100 000 persons was derived.In our neurosurgery department, the number of referrals of patients with SIH and the corresponding catchment area have grown steadily larger: 25 patients with SIH were treated in 2016 and another 25 in 2017, 35 in 2018, and 89 in 2019. Women are affected twice as commonly as men; the average age of onset is 40 years (7,(11)(12).The condition is pathogenetically separated from that of postlumbar puncture headache and from postoperative cerebrospinal fluid (CSF) loss (13). Clinical differential diagnoses include postural orthostatic tachycardia syndrome (POTS), Chiari I malformation, and cervicogenic headache (12, 13). Clinical featuresThe most prominent symptom is positionally dependent headache that is worse in the standing position and tends to increase in severity over the course of the day. Rapid onset is typical: most patients can identify "the day it all began" (14, 15). The positional dependence of the headache, and its being most pronounced in the back of the head, can be explained as the result of the the following causal sequence: low CSF volume-sagging of the brain-tension on the cranial nerves and dura mater. The dura mater of the posterior fossa is especially sensitive to tension (14).

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“…With one or more epidural blood patches, 30-70% of SIH patients show marked improvement; however, a permanent cure in types 1 and 2 leaks is achieved in less than 10% of patients [38,39]. There is no consensus how to perform a blood patch ("loss of resistance," fluoroscopy-guided, CTguided, blood, or fibrin glue) and whether it must be placed precisely over the site of the spinal CSF leak or it might suffice to raise the pressure in the epidural space [40][41][42][43][44]. Punctures at multiple lumbar levels may be needed to deliver the epidural blood to the site of the leak; the technique involves demonstration of an uninterrupted flow of contrast medium (and thus, presumably, of the subsequently injected blood as well) epidurally in the cranial direction.…”

Section: Therapeutic Proceduresmentioning

confidence: 99%

Spontaneous intracranial hypotension: diagnostic and therapeutic workup

et al. 2021

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Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with typical MRI findings among which engorgement of the venous sinuses, pachymeningeal enhancement, and effacement of the suprasellar cistern have the highest diagnostic sensitivity. SIH is in almost all cases caused by spinal CSF leaks. Spinal MRI scans showing so-called spinal longitudinal extradural fluid (SLEC) are suggestive of ventral dural tears (type 1 leak) which are located with prone dynamic (digital subtraction) myelography. As around half of the ventral dural tears are located in the upper thoracic spine, additional prone dynamic CT myelography is often needed. Leaking nerve root sleeves typically associated with meningeal diverticulae (type 2 leaks) and CSF-venous fistulas (type 3 leaks) are proven via lateral decubitus dynamic digital subtraction or CT myelography: type 2 leaks are SLEC-positive if the tear is proximal and SLEC-negative if it is distal, and type 3 leaks are always SLEC-negative. Although 30–70% of SIH patients show marked improvement following epidural blood patches applied via various techniques definite cure mostly requires surgical closure of ventral dural tears and surgical ligations of leaking nerve root sleeves associated with meningeal diverticulae or CSF-venous fistulas. For the latter, transvenous embolization with liquid embolic agents via the azygos vein system is a novel and valuable therapeutic alternative.

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Clinical effect of the proximity of epidural blood patch injection to the leakage site in spontaneous intracranial hypotension

Cited by 13 publications

References 24 publications

Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension

Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension

Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension: diagnostic and therapeutic workup

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