Epidural Fibrin Sealant Injection for the Management of Cerebrospinal Fluid Leak Following Dural Puncture in Children

Abstract

Cerebrospinal fluid (CSF) leak, intracranial hypotension, and postdural puncture headaches are common following dural punctures. Management usually consists of conservative treatments with medications (e.g. caffeine, nonsteroidal anti-inflammatory drugs, steroids, opioids), increased fluid intake, and bed rest. In more severe and persistent cases, epidural blood patches (EBPs) are indicated. When multiple EBPs fail, epidural injection of fibrin sealant has been successful in a few reported adult cases. The authors describe the first reported clinical experiences of epidural fibrin patch in children for repair of CSF leak and resolution of intracranial hypotension. This technique was used in three cases where serial EBPs failed to resolve symptoms related to intracranial hypotension following dural puncture. Following the procedure, each patient had resolution of their presenting clinical symptoms and radiographic abnormalities, and there were no noted complications. Epidural fibrin sealant injection is a reasonable option for relieving intracranial hypotension due to CSF leak following dural puncture in children.

Management of Post-Dural Puncture Headaches in Pediatric Patients with Epidural Blood or Saline Patch: An Educational Focused Review

“…Aside from previous reports of successful primary EBP, there are additional anecdotal reports involving repeat EBP, ESP, and epidural fibrin glue (Table 2). [61][62][63][64][65] These reports include a total of 7 patients from 4 case reports and one case series. Similar to the reports outlined in Table 1, the patients varied in age from 4 to 14 years old.…”

Chronic headaches related to post-dural puncture headaches: a scoping review

“…31 In the event of failed EBP, several authors have attempted fibrin glue injection, all of them reporting excellent outcomes. 23,26,28,38 One of the three patients covered in this review required a repeat injection which was successful at inducing a durable remission of headaches at 7 months. The volume of fibrin glue injected ranged from 3 to 5 ml.…”

A Study of Safety and Effectiveness of Evicel Fibrin Sealant as an Adjunctive Hemostat in Pediatric Surgery

“…14,15 In EU, Evicel is also indicated as suture support in vascular surgery and for suture line sealing in dura mater closure; however, it is not yet approved in children. 15 Observational data have supported the efficacy of FSs as sealants/adhesives in children treated for dural puncture leakage, 16,17 peritoneal catheter cuff leakage, [18][19][20] and other conditions, [21][22][23][24][25][26] and these studies did not raise any safety concerns. A shortage of clinical data exists, however, on the use of FSs to control intraoperative bleeding in pediatric patients.…”