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

Abstract

An epidural blood patch (EBP) is the mainstay of treatment for refractory spontaneous intracranial hypotension (SIH). We evaluated the treatment efficacy of targeted EBP in refractory SIH. All patients underwent brain magnetic resonance imaging (MRI) with contrast and heavily T2-weighted spine MRI. Whole spine computed tomography (CT) myelography with non-ionic contrast was performed in 46 patients, and whole spine MR myelography with intrathecal gadolinium was performed in 119 patients. Targeted EBPs were placed in the prone position one or two vertebral levels below the cerebrospinal fluid (CSF) leaks. Repeat EBPs were offered at 1-week intervals to patients with persistent symptoms, continued CSF leakage, or with multiple leakage sites. Brain MRIs showed pachymeningeal enhancement in 127 patients and subdural hematomas in 32 patients. One hundred fifty-two patients had CSF leakages on heavily T2-weighted spine MRIs. CSF leaks were also detected on CT and MR myelography in 43 and 111 patients, respectively. Good recovery was achieved in all patients after targeted EBP. No serious complications occurred in patients treated with targeted EBP during the 1 to 7 years of follow-up. Targeted and repeat EBPs are rational choices for treatment of refractory SIH caused by CSF leakage.

The Glymphatic System: A Review of the Challenges in Visualizing its Structure and Function with MR Imaging

“…Some centers have safely administered small intrathecal doses of GBCA in 100 or more patients as clinical research. 47,48 A study in eight healthy human adult volunteers quantified CSF transport kinetics and brain glymphatic distribution using MR imaging following lumbar intrathecal injection of GBCA. 49 After intrathecal administration, the GBCA was observed in the basal cisterns by the first imaging time point (1.8 hrs), and GBCA in the intracranial CSF spaces peaked within 1-3 hrs and started to decrease by 7 hrs.…”

Targeted Epidural Blood Patch Treatment for Refractory Spontaneous Intracranial Hypotension: A Case Report

“…In our patient, MRM spinal imaging technique was considered first, because we believe that the site of CSF leakage can efficiently and safely be identified, and the location of the tear can be identified accurately. 9 Therefore, we opine that EBP procedures should be performed as near to the leakage site as possible to improve the efficacy and success rate. This patient's puncture point below the MRM demonstrated CSF leakage.…”

Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment

“…Neck pain and stiffness, photophobia, and phonophobia may also often appear due to meningeal irritation [11]. Other accompanying features involve vertigo, tinnitus, visual disturbances such as blurred vision or bitemporal hemianopia, dysgeusia, hearing loss, gait ataxia, radicular arm pain, and cranial nerve deficits, such as diplopia, most frequently due to VI palsy, facial weakness, or numbness [1,2,7,11,[23][24][25]. Although much rarer, cognitive decline [26], parkinsonism [27], chorea [28], quadriplegia [29], seizures [2], Meniere-like syndrome [30], hyperprolactinemia, and galactorrhea [3], as well as positional loss of consciousness and coma due to diencephalic herniation [31], have been also reported.…”

“…Sometimes, multiple sites of CSF leaks are identified [3]. Indicative signs include epidural effusions, dilated intradural veins, and dural enhancement diffusely or focally at the site of leakage, most commonly in the cervical and thoracic region [2,23,39]. Interestingly, the "floating dural sac sign," which is a hyperintense rim or band around the dural sac on axial spinal T2-weighted MRI images, has been proposed as a sensitive sign of CSF leakage (sensitivity and specificity 93%) [40].…”