Spontaneous intracranial hypotension syndrome treated with a double epidural blood patch

Abstract

Spontaneous intracranial hypotension (SIH) is considered to be a very rare disease. It is characterised by an orthostatic headache in the absence of a past history of a trauma or a dural puncture. SIH is caused by a spontaneous spinal cerebrospinal fluid (CSF) leakage demonstrated by neuroradiological studies in most of the patients. Conservative treatment usually includes bed rest, hydration and administration of caffeine or steroids. However, when the patient is refractory to the conservative treatment, an epidural blood patch (EBP) is performed. We report a 34-year-old woman with SIH and no neuroradiologically demonstrable clear point of CSF leakage, who was treated with a double EBP at two different levels (lumbar and thoracic) in the same procedure. The patient was successfully managed, and she was still asymptomatic at the 18 months follow-up. After review of literature, we observed that execution of a double EBP at the same time is not a common procedure for treatment of SIH. We consider that simultaneous use of two EBP could be useful as a novel treatment in those cases of SIH without demonstration of CSF leakage.

C1-C2 cryptic cerebrospinal fluid leak directly identified by pressurized radionuclide cisternography: Case report and review of the literature

“…EBP is the treatment of choice in patients who have failed an initial trial of conservative management. [ 3 31 ] EBPs have been shown to spread within the epidural space over many spinal levels,[ 3 30 33 ] which argues the necessity of finding the precise level of dural rent when percutaneous treatment measures are used. Failure of EBP therapy or recurrence after initial success seems to be common in patients with a cervical CSF leak.…”

Reply to ‘missed citation?’

“…Sir, With great interest, we read the article by Dr Böhmer and colleagues regarding the implementation of a perioperative checklist and its subsequent effect on patient safety and staff satisfaction. 1 The authors conclude that, from the operating room (OR) staff's perspective, perioperative safety-relevant factors can be handled significantly better and with greater awareness if a safety checklist as proposed by the World Health Organization is implemented. 2 We would like to highlight some issues with this study.…”

“…participation of the staff, specific adaptation of the checklist to local conditions, example setting at the management level, and gathering as well as presenting the baseline and improvement findings after introduction of the checklist. 1 Nevertheless, they do not expand on how the checklist was adapted to their specific setting, nor on the implementation process as a whole. This is unfortunate; as such information would be highly meaningful for others involved in introducing quality improvement initiatives such as the safety checklist in their institution.…”

“…Br J Anaesth 2010; 105: 868-69.Sir, We would like to show gratitude to P. Feltracco et al for their letter commenting our case report entitled 'Spontaneous intracranial hypotension (SIH) treated with a double epidural blood patch (EBP)'. 1 We reported the case of a patient with history of SIH treated with two 'blind' EBPs at two different levels (lumbar and thoracic) in the same procedure. This fact was justified by trying to cover a more extensive area with the simultaneous patches, thereby offering a higher probability of success to the patient.We referred in the paper the infrequent use of a double simultaneous EBP for treatment of SIH and the only find by the authors of a case report where this procedure was performed.…”

Treatment of spontaneous intracranial hypotension with epidural blood patch: is a complex approach necessary or better than a simple one?

“…The study of Belina et al. is intriguing, but a larger series would be needed for comparison with the results of other series noted earlier consisting of 28–43 subjects each . Until then, a firm recommendation regarding single or double site administration of EBP in treatment of SIH cannot be made.…”