Spontaneous C1-2 CSF Leak Treated with High Cervical Epidural Blood Patch

Abstract

Spontaneous intracranial hypotension (SIH) is a condition caused by spontaneous spinal cerebrospinal fluid (CSF) leaks. Clinically, it is characterized by orthostatic headache and may respond well to epidural blood patch. Other neurological presentations of SIH include diplopia, memory loss, hearing deficits, Parkinsonism, ataxia, obtundation and even coma.Magnetic resonance imaging (MRI) is crucial in the diagnosis of this condition. Typical radiological features include diffuse pachymeningeal enhancement, descent of the cerebellar tonsil, a decrease in the size of prepontine and perichiasmatic cisterns, and subdural fluid collections. However, radiological imaging such as radionuclide cisternography or spinal MRI are not reliable in detecting the site of leakage. Myelography with iodinated contrast followed by thin-cut computed tomography (CT) or MRI of the entire spine has been shown as the technique of choice in defining the location of the CSF leak.

Targeted Epidural Blood Patch Treatment for Refractory Spontaneous Intracranial Hypotension in China

“…An EBP is the preferred treatment for patients who have failed a conservative approach. 6 Because of the rarity of SIH, evidence for the efficacy of EBP is insufficient, and a uniform protocol on how to perform an EBP has not been established worldwide; [7][8][9][10][11] Currently, the standard of care for SIH patients is predominantly comprised of conservative treatment in most Chinese medical communities, including patients with refractory SIH. Therefore, in the present study, we assessed the treatment efficacy of targeted EBPs (patches delivered directly to the site of CSF leakage) for refractory SIH patients after identification of the CSF leakage via an imageologic examination in our institution.…”

Intracranial Hypotension Causing Reversible Frontotemporal Dementia and Coma

“…Lumbar epidural blood patching failed in this patient, necessitating surgical repair of the leak with epidural muscle packing and fibrin glue injection; however, no targeted cervical epidural blood patch (EBP) was attempted. One other case of a targeted EBP for a C1-C2 CSF leak site has been reported to date; however, in this case the patch was introduced at the C4 level, below the leak site, and was repeated twice before the patient achieved symptomatic improvement 32 .…”

“…Failing conservative medical management, one should consider the use of an epidural blood patch to seal dural CSF leaks 5,9,10,19,28,29,31,32 . The proposed mechanism for the efficacy of blood patching is two fold: an initial displacement of the dura towards the spinal cord moves peri-spinal CSF into cranium, thus immediately increasing intracranial CSF volume, pressure and buoyancy forces; and later, as blood coagulates at the leak site, further CSF loss is prevented.…”

Repeated large-volume epidural blood patches for the treatment of spontaneous intracranial hypotension

“…Although EBP is considered the mainstay of treatment for PDPH, evidence for its effectiveness in SIH is limited and comes primarily from case reports and series. [2][3][4][5][6][7][8][9][10] The success rate for an EBP is variable and depends on the size of the dural hole, timing of the EBP, and possibly the volume of blood used. In the obstetric population, a success rate of 70% for a single EBP has been reported, but 15% of patients needed a second or a third EBP to treat a PDPH from an inadvertent dural puncture with an epidural needle.…”