Lumbar epidural blood patch: effectiveness on orthostatic headache and MRI predictive factors in 101 consecutive patients affected by spontaneous intracranial hypotension

Cervical epidural blood patch treatment is a choice for spontaneous intracranial hypotension

BACKGROUND

Epidural blood patch (EBP) is a minimally invasive and effective treatment for spontaneous intracranial hypotension (SIH). But, cervical epidural blood patch for SIH has little attention.

OBJECTIVE

In this study, The clinical data was recorded and the treatment efficacy and safety of cervical EBP in SIH were evaluated.

METHODS

: Fifty-nine cases of intractable SIH were examined by computed tomography (CT) guided cervical EBP at the Chinese PLA General Hospital from August 2014 to March 2024.

RESULTS

The mean age of the fifty-nine patients at symptom onset was 40.8 ± 9.5 years. 54/59 (91.5%) patients experienced orthostatic headache. Preoperative spine T2 sacns with extensive fluid collection at the upper cervical region in 43/46 (93.5%). 45/59 (76.3%) patients had symptomatic relief with initial cervical EBP, and 14/59 (23.7%) patients received further cervical EBPs. In the first one to three days following the EBP procedure, 11 (18.6%) patients reported pain at the puncture site and 15 (25.4%) experienced neck pain. No other complications were observed during or after the procedure. At the latest follow-up, all patients showed good recovery. The mean follow-up was 28.9 ± 22.7 months.

CONCLUSION

CT-guided cervical EBP is a effective and safe treatment for patients with intractable SIH, especially in patients who had extensive fluid collection at the upper cervical region.

Acquired tonsillar herniation related to spontaneous intracranial hypotension: case reports

Background

Acquired prolapse of the cerebellar tonsils in spontaneous intracranial hypotension (SIH) patients is rare. This study aims to evaluate neuroimaging changes of acquired prolapse of the cerebellar tonsils below the foramen magnum in SIH patients due to spontaneous spinal cerebrospinal fluid leakage, which was treated by targeted epidural blood patches (EBP).

Methods

We retrospectively reviewed clinical and neuroimaging characteristics of 5 cases of SIH with acquired prolapse of the cerebellar tonsils that received targeted EBP in our institution from January 2013 to December 2016.

Results

Of these SIH patients, all of them suffered from an orthostatic headache. Initial cranial MRI demonstrated descent of the cerebellar tonsils ≥5 mm. Intrathecal gadolinium-enhanced spinal MR myelography and/or spinal MR hydrography were performed to evaluate the level of spinal cerebrospinal fluid leakage. Symptoms were alleviated in all 5 patients after two (n = 4), or three (n = 1) targeted EBP during hospitalization. Follow-up cranial MRI revealed that the descent of cerebellar tonsils was reversed after EBP treatment.

Conclusion

Acquired tonsillar herniation can occur in patients with SIH and spinal cerebrospinal fluid leakage. Symptoms of these patients may be resolved and radiologic findings may be reversed after EBP treatment.

A technique to localize posteriorly located spinal dural leaks associated with spontaneous intracranial hypotension: Dorsal-decubitus dynamic CT myelography

BACKGROUND

Precise localization and understanding of the origin of cerebrospinal fluid (CSF) leak is crucial to allow targeted treatment. We report the technical feasibility and utility of dorsal-decubitus dynamic computed tomography (DDDCT) myelography to localize posteriorly located dural defects in patients with suspicion of posterolateral dural tears.

METHODS

This study reports a series of four consecutive patients with posteriorly located SLEC and suspicion of posterolateral CSF leak who received DDDCT to localize the site of the leak. Patients were collected between October 2022 and October 2023. The technique of DDDCT and its efficacy to detect the site of CSF leak are reported.

RESULTS

In all four patients (three females, one male, mean age 39 years), DDDCT myelography was technically successful and precisely demonstrated the site of the CSF leak. In one patient with both anterior and posterior SLEC, DDDCT allowed to exclude the presence of a posteriorly located leak, while a subsequent ventral decubitus dynamic CT myelography localized the leak. Leak sites were all thoracic, except for one that was cervical. Information obtained from the DDDCT myelography was considered useful to target the treatment of the leak.

CONCLUSIONS

Based on our experience, DDDCT provided sufficient spatial and temporal resolution to pinpoint fast CSF leaks and it may be considered to localize posterolateral dural defects.

Efficacy of Epidural Blood Patching or Surgery in Spontaneous Intracranial Hypotension: A Systematic Review and Evidence Map

BACKGROUND

Spontaneous intracranial hypotension is an important cause of treatable secondary headaches. Evidence on the efficacy of epidural blood patching and surgery for spontaneous intracranial hypotension has not been synthesized.

PURPOSE

Our aim was to identify evidence clusters and knowledge gaps in the efficacy of treatments for spontaneous intracranial hypotension to prioritize future research.

DATA SOURCES

We searched published English language articles on MEDLINE (Ovid), the Web of Science (Clarivate), and EMBASE (Elsevier) from inception until October 29, 2021.

STUDY SELECTION

We reviewed experimental, observational, and systematic review studies assessing the efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension.

DATA ANALYSIS

One author performed data extraction, and a second verified it. Disagreements were resolved by consensus or adjudicated by a third author.

DATA SYNTHESIS

One hundred thirty-nine studies were included (median, 14 participants; range, 3-298 participants). Most articles were published in the past decade. Most assessed epidural blood patching outcomes. No studies met level 1 evidence. Most were retrospective cohort or case series (92.1%, n = 128). A few compared the efficacy of different treatments (10.8%, n = 15). Most used objective methods for the diagnosis of spontaneous intracranial hypotension (62.3%, n = 86); however, 37.7% (n = 52) did not clearly meet the International Classification of Headache Disorders-3 criteria. CSF leak type was unclear in 77.7% (n = 108). Nearly all reported patient symptoms using unvalidated measures (84.9%, n = 118). Outcomes were rarely collected at uniform prespecified time points.

LIMITATIONS

The investigation did not include transvenous embolization of CSF-to-venous fistulas.

CONCLUSIONS

Evidence gaps demonstrate a need for prospective study designs, clinical trials, and comparative studies. We recommend using the International Classification of Headache Disorders-3 diagnostic criteria, explicit reporting of CSF leak subtype, inclusion of key procedural details, and using objective validated outcome measures collected at uniform time points.

Diagnosis and treatment evaluation in patients with spontaneous intracranial hypotension

Spontaneous intracranial hypotension is characterized by an orthostatic headache and audiovestibular symptoms alongside a myriad of other non-specific symptoms. It is caused by an unregulated loss of cerebrospinal fluid at the spinal level. Indirect features of CSF leaks are seen on brain imaging as signs of intracranial hypotension and/or CSF hypovolaemia as well as a low opening pressure on lumbar puncture. Direct evidence of CSF leaks can frequently, but not invariably, be observed on spinal imaging. The condition is frequently misdiagnosed due to its vague symptoms and a lack of awareness of the condition amongst the non-neurological specialities. There is also a distinct lack of consensus on which of the many investigative and treatment options available to use when managing suspected CSF leaks. The aim of this article is to review the current literature on spontaneous intracranial hypotension and its clinical presentation, preferred investigation modalities, and most efficacious treatment options. By doing so, we hope to provide a framework on how to approach a patient with suspected spontaneous intracranial hypotension and help minimize diagnostic and treatment delays in order to improve clinical outcomes.

Epidural Blood Patching in Spontaneous Intracranial Hypotension-Do we Really Seal the Leak?

PURPOSE

Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH). Follow-up after EBP primarily relies on clinical presentation and data demonstrating successful sealing of the underlying spinal cerebrospinal fluid (CSF) leak are lacking. Our aim was to evaluate the rate of successfully sealed spinal CSF leaks in SIH patients after non-targeted EBP.

METHODS

Patients with SIH and a confirmed spinal CSF leak who had been treated with non-targeted EBP were retrospectively analyzed. Primary outcome was persistence of CSF leak on spine MRI or intraoperatively. Secondary outcome was change in clinical symptoms after EBP.

RESULTS

In this study 51 SIH patients (mean age, 47 ± 13 years; 33/51, 65% female) treated with non-targeted EBP (mean, 1.3 EBPs per person; range, 1-4) were analyzed. Overall, 36/51 (71%) patients had a persistent spinal CSF leak after EBP on postinterventional imaging and/or intraoperatively. In a best-case scenario accounting for missing data, the success rate of sealing a spinal CSF leak with an EBP was 29%. Complete or substantial symptom improvement in the short term was reported in 45/51 (88%), and in the long term in 17/51 (33%) patients.

CONCLUSION

Non-targeted EBP is an effective symptomatic treatment providing short-term relief in a substantial number of SIH patients; however, successful sealing of the underlying spinal CSF leak by EBP is rare, which might explain the high rate of delayed symptom recurrence. The potentially irreversible and severe morbidity associated with long-standing intracranial hypotension supports permanent closure of the leak.

Intracranial hypotension in a breast cancer patient treated with epidural blood patches

We report the case of a patient with metastatic breast cancer who presented with an orthostatic headache. After a comprehensive diagnostic workup including MRI and lumbar puncture, we maintained the diagnosis of intracranial hypotension (IH). The patient was therefore treated with two consecutive non targeted epidural blood patches, resulting in the remission of IH symptoms for 6 months. IH in cancer patients is a rarer cause of headache than carcinomatous meningitis. As the diagnosis can be made by standard examination and the treatment is relatively simple and effective, IH deserves to be better known by oncologists.

The SIH-EBP Score: A grading scale to predict the response to the first epidural blood patch in spontaneous intracranial hypotension

BACKGROUND

To develop and validate an easy-to-use scoring system to predict the response to the first epidural blood patching in patients with spontaneous intracranial hypotension.

METHODS

This study recruited consecutive patients with spontaneous intracranial hypotension receiving epidural blood patching in a tertiary medical center, which were chronologically divided into a derivation cohort and a validation cohort. In the derivation cohort, factors associated with the first epidural blood patching response were identified by using multivariable logistic regression modeling. A scoring system was developed, and the cutoff score was determined by using the receiver operating characteristic curve. The findings were verified in an independent validation cohort.

RESULTS

The study involved 280 patients in the derivation cohort and 78 patients in the validation cohort. The spontaneous intracranial hypotension-epidural blood patching score (range 0-5) included two clinical variables (sex and age) and two radiological variables (midbrain-pons angle and anterior epidural cerebrospinal fluid collections). A score of ≥3 was predictive of the first epidural blood patching response, which was consistent in the validation cohort. Overall, patients who scored ≥3 were more likely to respond to the first epidural blood patching (odds ratio = 10.3).

CONCLUSION

For patients with spontaneous intracranial hypotension-epidural blood patching score ≥3, it is prudent to attempt at least one targeted epidural blood patching before considering more invasive interventions.

Diagnostic approach, therapeutic strategies, and surgical indications in intradural thoracic disc herniation associated with CSF leak, intracranial hypotension, and CNS superficial siderosis

Background and purpose

Intradural disc herniation (IDH) can manifest with radicular or medullary syndrome. In about 15% of cases, IDH may be responsible, through a dural laceration, for a CSF leak, determining spontaneous intracranial hypotension (SIH) and CNS superficial siderosis (CNSss). This paper attempts to present an overview on IDH as the cause for both CSF leak, and subsequent SIH, and CNSss, and to describe a peculiar clinical and neuroradiological scenario related to this condition.

Methods

A search on the PUBMED database was performed. Although the investigation did not rigorously follow the criteria for a systematic review (we consider only articles about thoracic IDH), nonetheless, the best quality evidence was pursued. Furthermore, an illustrative case was presented.

Results

A 69-year-old woman was referred to our hospital for slowly progressive gait disturbances and hearing impairment. Brain imaging revealed diffuse bilateral supratentorial and infratentorial superficial siderosis, mostly of the cerebellum, the eighth cranial nerves, and the brainstem. Spinal imaging disclosed a posterior disc herniation determining a dural tear at D6-D7. Lumbar puncture revealed low opening pressure and hemorrhagic CSF with siderophages. A posterior transdural herniectomy and dural sealing determined a stabilization of hearing and a significant improvement in both gait and balance.

Conclusions

The diagnostic workup of CNSss with suspected CNS leak demands whole neuraxis imaging, especially in cases presenting SIH or myelopathic symptoms. This may avoid delays in detection of IDH and spinal dural leaks. The different forms of treatment available depend on the type and severity of the clinical picture.

Risk factors associated with repeated epidural blood patches using autologous blood

Background

An epidural blood patch (EBP) is a procedure to treat intracranial hypotension that does not respond to conservative treatment. EBPs are commonly repeated when the symptoms persist. In this study, we used a large single-center retrospective cohort and evaluated the factors associated with repeated EBPs.

Methods

From January 2010 to December 2020, a total of 596 patients were treated with EBPs for intracranial hypotension. We evaluated the factors associated with repeated EBPs in the entire population, in patients with spontaneous intracranial hypotension (SIH), and in those with available myelographies.

Results

In a total of 596 patients, 125 (21.1%) patients required repeated EBPs, and 96/278 (34.5%) in SIH and 29/314 (9.2%) in iatrogenic population. In patients with SIH, international normalized ratio (INR) and cerebrospinal fluid (CSF) leakage on myelographies consistently exhibited significant associations (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.02-1.87; P = 0.043 and OR, 2.18; 95% CI, 1.28-3.69; P = 0.004). In patients with iatrogenic injury, INR and CSF leakage on myelogram did not show difference in repeated EBPs.

Conclusions

Repeated EBPs may be more frequently required in patients with SIH. Prolonged INR and CSF leakage were associated with repeated EBPs in patient with SIH. Further studies are needed to determine factors associated with repeated EBP requirements.

Dural sac shrinkage signs on magnetic resonance imaging at the thoracic level in spontaneous intracranial hypotension-its clinical significance

BACKGROUND

Spontaneous intracranial hypotension (SIH) is secondary to a cerebrospinal fluid leak at the spinal level without obvious causative events. Several signs on brain and cervical spine magnetic resonance (MR) imaging (MRI) have been associated with SIH but can be equivocal or negative. This retrospective study sought to identify characteristic SIH signs on thoracic spinal MRI.

METHODS

Cranial and spinal MR images of 27 consecutive patients with classic SIH symptoms, who eventually received epidural autologous blood patches (EBPs), were analyzed.

RESULTS

The most prevalent findings on T2-weighted MRI at the thoracic level were anterior shift of the spinal cord (96.3%) and dorsal dura mater (81.5%), probably caused by dural sac shrinkage. These dural sac shrinkage signs (DSSS) were frequently accompanied by cerebrospinal fluid collection in the posterior epidural space (77.8%) and a prominent epidural venous plexus (77.8%). These findings disappeared in all six patients who underwent post-EBP spinal MRI. Dural enhancement and brain sagging were minimum or absent on the cranial MR images of seven patients, although DSSS were obvious in these seven patients. For 23 patients with SIH and 28 healthy volunteers, a diagnostic test using thoracic MRI was performed by 13 experts to validate the usefulness of DSSS. The median sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy of the DSSS were high (range, 0.913-0.931).

CONCLUSIONS

Detection of DSSS on thoracic MRI facilitates an SIH diagnosis without the use of invasive imaging modalities. The DSSS were positive even in patients in whom classic cranial MRI signs for SIH were equivocal or minimal.

Predictors Associated with Outcomes of Epidural Blood Patch in Patients with Spontaneous Intracranial Hypotension

An autologous epidural blood patch (EBP) is a mainstay of treatment in patients with spontaneous intracranial hypotension (SIH). EBP, however, is less effective for SIH than post-dural puncture headaches. Therefore, patients with SIH frequently require an additional EBP. The aim of this study was to identify factors associated with poor response to EBP. This single-center retrospective observational study used the institutional registry records of 321 patients who underwent EBP between September 2001 and March 2016. Patients were divided into two groups, a poor responder group, consisting of patients who underwent EBP at least three times or more, and a good responder group of patients who experienced sufficient symptom relief after two or fewer EBP. The demographic characteristics, clinical features, radiologic findings, procedural data, and laboratory data were analyzed. Univariate analysis showed that the neutrophil-to-lymphocyte ratio (NLR; p = 0.004) and platelet-to-lymphocyte ratio (p = 0.015) were significantly lower in poor than in good responders. Multivariate analysis found that NLR was the only independent factor associated with a poor response (odds ratio = 0.720; p = 0.008). These findings indicate that a low NLR was associated with three or more EBP administrations for the sufficient improvement of symptoms in patients with SIH.