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Mark I, Madhavan A, Carr C, Cutsforth-Gregory J. Intrathecal hematoma following epidural blood patch: An alternative mechanism to intrathecal puncture. Neuroradiol J 2024:19714009241242587. [PMID: 38520266 DOI: 10.1177/19714009241242587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024] Open
Abstract
Intrathecal blood after a percutaneous epidural blood patch is a known complication, one that has been previously attributed to inadvertent needle tip position in the subarachnoid space. We present two cases with imaging confirmation of an alternative mechanism, one that includes blood transferring from the epidural space to the subarachnoid space through a pre-existing dural defect.
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Affiliation(s)
- Ian Mark
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ajay Madhavan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Carrie Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Chen YC, Yang FC, Huang GS, Chang WC, Hsu YC. Value of CT in targeted CT-guided epidural blood patching: Predictors for successful epidural punctures. J Neuroradiol 2024; 51:204-209. [PMID: 37758171 DOI: 10.1016/j.neurad.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/24/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND PURPOSE Differentiating epidural from intrathecal punctures before computed tomography (CT)-guided epidural blood patching (EBP) is subjective, relying on operator experience. This study aimed to investigate CT findings for epidural and intrathecal punctures and identify reliable predictors for successful epidural punctures before targeted CT-guided EBP. MATERIALS AND METHODS We included 65 patients with low-cerebrospinal fluid (CSF)-pressure headache receiving targeted CT-guided EBP between January 2021 and October 2022 in this retrospective study. We analyzed clinical data, technical information, and CT features before EBP. Fisher's exact test was used for discrete variables, while Mann-Whitney U test was used for continuous variables. Positive (PLR) and negative likelihood ratios (NLR) were calculated to identify predictors for confirming epidural punctures. RESULTS We confirmed 43 patients as epidural punctures and 22 patients as intrathecal punctures. Before contrast injection, epidural fat at the needle tip in the epidural group was higher than the intrathecal group (37.2 % [16/43] vs. 4.5 % [1/22], p = 0.006). After contrast injection, the "contrast-needle tip connection" sign was mostly observed in the epidural group than the intrathecal group (95.3 % [41/43] vs. 9.1 % [2/22], p < 0.001). Additionally, the epidural group had significantly higher boomerang-shaped contrast morphology than the intrathecal group (65.1 % [28/43] vs. 9.1 % [2/22], p < 0.001). The "contrast-needle tip connection" sign had the highest PLR (10.49) and lowest NLR (0.05). CONCLUSION Identifying epidural fat at the needle tip, "contrast-needle tip connection" sign, and boomerang-shaped contrast morphology on CT scans are useful for confirming proper placement of the needle tip within the epidural space.
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Affiliation(s)
- Ya-Che Chen
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan; Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Yi-Chih Hsu
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan.
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Ito Y, Bhagwat A. Intrathecal haematoma after an epidural blood patch. BMJ Case Rep 2022; 15:e246725. [PMID: 36175040 PMCID: PMC9528484 DOI: 10.1136/bcr-2021-246725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
SummaryThis case demonstrates a rare but potentially serious complication of an epidural blood patch (EBP). Intrathecal haematoma is a rare complication after an EBP and anaesthetists should be able to promptly identify and manage these patients to prevent long-term damage. This case also highlights the importance of informed consent according to the principles of the Montgomery judgement/principle of consent.
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Affiliation(s)
- Yoshimi Ito
- Anaesthesia and Critical Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Amit Bhagwat
- Anaesthesia and Critical Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
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Lv Y, Xiang H. Seizures and Consciousness Disorder Secondary to Intracranial Hypotension After Spinal Surgery: A Case Report and Literature Review. Front Neurol 2022; 13:923529. [PMID: 35832179 PMCID: PMC9271921 DOI: 10.3389/fneur.2022.923529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/02/2022] [Indexed: 12/04/2022] Open
Abstract
Rationale Cerebrospinal fluid (CSF) leakage is a common condition after spinal surgery and is also the most common cause of intracranial hypotension. Intracranial hypotension (IH) is typically characterized by an orthostatic headache with associated nausea, vomiting, tinnitus, vertigo, hypoacusis, neck stiffness, and photophobia. There have been limited case reports describing surgery-associated IH presenting with seizures and disorder of consciousness. Due to the atypia of symptoms, these clinical manifestations are usually ignored or even misdiagnosed. As a result, clinicians face a significant challenge in detecting IH early and understanding its various clinical presentations. Meanwhile, we summarize the cases of IH presenting as seizures in recent years, including its clinical characteristics and effective treatment, which will be very helpful for the early diagnosis of IH. Patient concerns A 72-year-old Chinese male patient developed status epilepticus, a disorder of consciousness, and quadriplegia when he finished spinal surgery, although he had no previous seizures or any seizure risk factors. Diagnosis After MRI and CT examination, subdural hygromas were found under both sides of the skull, and combined with the clinical manifestations of the patient, intracranial hypotension due to cerebrospinal fluid leakage was diagnosed. Interventions In the early stage, we carried out strict perioperative critical care for the patient. Trendelenburg position was conducted to relieve intracranial hypotension. The dural repair surgery was performed after the diagnosis of CSF leakage. Outcomes Seizures in the patient were resolved. Three months after discharge, he was gradually returning to normal life. Lessons One possible cause of unexplained seizures and disorder of consciousness after spinal surgery is cerebrospinal fluid leakage associated with intracranial hypotension syndrome. Trendelenburg position and dural repair surgery are effective ways to relieve intracranial hypotension and associated symptoms. Better awareness of the association between IH (intracranial hypotension) and seizures may help us improve early recognition of the syndrome.
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Affiliation(s)
- Yuqing Lv
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hui Xiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Hui Xiang
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Valença MM, e Sousa MSSM, Valença MA, Carvalho DED, Silva AHTTD, Andrade JRD. It is wrong to treat pain in CSF hypotension headache to allow the patient to walk! HEADACHE MEDICINE 2022. [DOI: 10.48208/headachemed.2021.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!
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Shin HY. Recent update on epidural blood patch. Anesth Pain Med (Seoul) 2022; 17:12-23. [PMID: 35038855 PMCID: PMC8841262 DOI: 10.17085/apm.21113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022] Open
Abstract
Epidural blood patch (EBP) is the injection of autologous blood into the epidural space with the intent of sealing off a dural tear and stopping the leakage of cerebrospinal fluid (CSF). EBP may cause an increase in intracranial pressure due to the mass effect of the injected blood volume, causing CSF from the spinal compartment to enter the intracranial compartment. EBP is usually considered in the management of moderate to severe headache (HA) attributed to low CSF pressure, such as post-dural puncture HA (PDPH), CSF fistula HA, and HA attributed to spontaneous intracranial hypotension (SIH) that does not respond to conservative management. However, prophylactic administration of EBP after accidental dural puncture can hardly be substantiated at present. EBP is generally safe but may rarely be associated with serious complications. Therefore, it should be carefully planned and performed under C-arm fluoroscopic guidance. Although many studies on PDPH and SIH have been conducted until recently, only few reviews have summarized the effectiveness of EBP from the perspective of a pain physician. This article reviews the current literature on the indication, contraindication, procedural consideration, post-procedural management, outcomes, and complications of EBP and the considerations for EBP in patients with COVID-19.
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Affiliation(s)
- Hwa Yong Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
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Chang YJ, Hung KC, Chen IW, Kuo CL, Teng IC, Lin MC, Yew M, Liao SW, Wu CY, Yu CH, Lan KM, Sun CK. Efficacy of greater occipital nerve block for pain relief in patients with postdural puncture headache: A meta-analysis. Medicine (Baltimore) 2021; 100:e28438. [PMID: 34941197 PMCID: PMC8701447 DOI: 10.1097/md.0000000000028438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/18/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND This study aimed at assessing the therapeutic effectiveness of greater occipital nerve block (GONB) against postdural puncture headache (PDPH). METHODS Studies investigating analgesic effects of GONB against PDPH in adults were retrieved from the MEDLINE, EMBASE, Google scholar, and Cochrane central databases from their inception dates to May, 2021. Pain score at postprocedural 24 hours was the primary endpoint, while secondary endpoints were pain score at postprocedural 1 hour and 12 hours as well as the risk of intervention failure. RESULTS Of the 7 studies (randomized controlled trials [RCTs], n = 4; non-RCTs, n = 3) that recruited 275 patients, 2 investigated female patients undergoing cesarean section and the other 5 were conducted in both obstetric and nonobstetric settings. Pooled results showed a lower mean pain score at 24 hours (i.e., primary outcome) (mean difference [MD] = -2.66, 95%: CI: -3.98 to -1.33, P < .001; I2 = 97%, 6 studies), 1 hour (MD = -4.23, 95% confidence interval [CI]: -5.08 to -3.37, P < .00001; I2 = 86%, 5 studies), and 6 hours (MD = -2.78, 95% CI: -4.99 to -0.57, P = .01; I2 = 98%, 4 studies) in patients with GONB compared to those without. Trial sequential analysis supported the robustness of evidence at postprocedural 24 hours. The use of GONB also decreased the risk of intervention failure (relative ratio [RR] = 0.4, 95% CI: 0.19 to 0.82, P = .01; I2 = 96%, 6 studies, 277 patients). CONCLUSION Our results suggested a therapeutic effect of greater occipital nerve block against postdural puncture headache up to postprocedural 24 hours. Further large-scale studies are warranted to evaluate its therapeutic benefit beyond the acute stage.
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Affiliation(s)
- Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chi-Lin Kuo
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Chia Teng
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ming-Chung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ming Yew
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Shu-Wei Liao
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chung-Yi Wu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Kuo-Mao Lan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan
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