Clinical Features, Neuroimaging and Treatment of Spontaneous Intracranial Hypotension and Magnetic Resonance Imaging Evidence of Blind Epidural Blood Patch

Su, Chen-San; Lan, Min-Yu; Chang, Yung‐Yee; Lin, Wei-Che; Liu, Kuan‐Ting

doi:10.1159/000206856

Cited by 43 publications

(24 citation statements)

References 62 publications

(40 reference statements)

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“…Long-term relief is thought to be due to formation of dural tamponade that seals the leak (14). Epidural blood patches have been shown to spread within the epidural space over many spinal levels (18), as was shown in the post-procedure CT for our patient.…”

Section: Discussionsupporting

confidence: 57%

“…It involves the injection of autologous blood into the epidural space, and has classically been performed in the lumbar region (14). Many advocate for using EBP without identifying a site of CSF leak (18). The success rate of EBP increases with the volume of blood used, with quotes of 80% success rate with 10-15 cc and >95% success rate with 20 cc of blood (14).…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

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

Girgis¹,

Shing²,

DuPlessis³

2013

Turkish Neurosurgery

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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.

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Section: Discussionsupporting

confidence: 57%

Section: Discussionmentioning

confidence: 99%

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

Girgis¹,

Shing²,

DuPlessis³

2013

Turkish Neurosurgery

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“…9,29 There are a few reports that observed a minor upward spread of a lumbar blood injection by up to 4 -6 spinal segments. 3,8,29 However, when blood is injected at a site distant from the CSF leak, it is difficult to conceive how the blood can traverse to the desired, remote location, with clotting commencing immediately after injection. Despite some reports of successfully treated CSF leaks with this method, animal experiments have shown that an EBP performed directly at the site of the leak will seal the dural defect more effectively than a blind epidural patch in the lumbar region.…”

Section: Discussionmentioning

confidence: 99%

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

Wendl¹,

Schambach²,

Zimmer³

et al. 2011

AJNR Am J Neuroradiol

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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 (...

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“…Placing an EBP far from the level of a leak was a possibility, but reported results are mixed. 9,10 Given that this patient was not an ideal operative candidate due to the nonlocalized nature of his leak and previous failed treatment with lumbar EBP, it was thought that a directed approach was reasonable.…”

Section: Discussionmentioning

confidence: 99%

Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension

Park

Villablanca

2012

AJNR Am J Neuroradiol

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SUMMARY:The dorsal epidural blood patch is a commonly used management technique for spontaneous intracranial hypotension from a dural CSF leak, but it may be less efficacious for cervical or ventral leaks. We report the technique of placing an anterior cervical blood patch for a large cervical ventral leak. To our best knowledge, this approach has not been reported. In the appropriately selected patient, an anterior cervical epidural blood patch may be safely used. ABBREVIATIONS:EBP ϭ epidural blood patch; IH ϭ intracranial hypotension; SIH ϭ spontaneous IH

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Clinical Features, Neuroimaging and Treatment of Spontaneous Intracranial Hypotension and Magnetic Resonance Imaging Evidence of Blind Epidural Blood Patch

Cited by 43 publications

References 62 publications

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

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

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension

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