Spontaneous Intracranial Hypotension: Clinical Presentation, Diagnosis, and Treatment Strategies

Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks. New evidence indicates that a lumbar puncture may not be essential for diagnosing every patient with SIH. Spinal neuroimaging protocols used for diagnosing and localizing spinal cerebrospinal fluid leaks include brain/spinal MRI, computed tomography myelography, digital subtraction myelography, and radionuclide cisternography. Complications of SIH include subdural hematoma, cerebral venous thrombosis, and superficial siderosis. Treatment options encompass conservative management, epidural blood patches, and surgical interventions. The early application of epidural blood patches in all patients with SIH is suggested.

Effect of blind versus fluoroscopic guidance epidural blood patch in patients with intracranial hypotension

Epidural blood patch (EBP)-the most effective treatment for intracranial hypotension (IH)-can be performed using the blind technique in the lateral position or under fluoroscopic guidance in the prone position. This study aimed to compare the effectiveness of EBP in patients with spontaneous intracranial hypotension (sIH) and iatrogenic intracranial hypotension (iIH) when performed with the blind technique in the lateral decubitus position or fluoroscopic guidance in the prone position. We reviewed IH patients who underwent EBP between January 2015 and September 2019 in a single hospital and divided them into two groups according to the type of IH. Of the 84 included patients, 36 had sIH and 48 had iIH. We compared the effectiveness of EBP using the two methods in each group. There was no significant difference in the effect of EBP between the patients with iIH (p > 0.05). For patients with sIH, fluoroscopic guidance in the prone position technique showed better improvement than the blind technique in the lateral decubitus position (p < 0.05). We observed similar outcomes after blind EBP versus fluoroscopic guidance EBP in patients with iIH. However, procedure-dependent differences were observed in patients with sIH. For patients with sIH, it would be effective to consider fluoroscopic EBP first. Further study is needed to investigate interactions between method of EBP and other factors that affect the effectiveness of EBP.

Spontaneous intracranial hypotension presenting with bilateral subdural hematoma: Decision-making and treatment strategies

BACKGROUND

The timing and decision to drain subdural hematoma (SDH) in spontaneous intracranial hypotension (SIH) remains a dilemma. We reviewed our experience of bilateral SDH secondary to SIH, focusing on decision making and treatment strategies.

METHODS

We retrospectively reviewed bilateral SDH secondary to SIH between March 2010 and September 2021. Baseline characteristics of patients, diagnosis, radiologic findings, treatments, and clinical outcome were investigated.

RESULTS

Fifteen patients (7 men, 8 women) with bilateral SDH secondary to SIH were included in this study. Initially, patients were treated conservatively (4 patients, 26.7 %), with an epidural blood patch (EBP, 3 patients, 20.0 %), and SDH drainage followed by the Trendelenburg position (8 patients, 53.3 %). All 3 patients that were initially treated with EBP required SDH drainage. Of the 8 patients initially treated with SDH drainage via burr hole followed by Trendelenburg position, 7 patients showed sustained improvements without EBP; however, 1 patient needed EBP. Deterioration to coma occurred in 6 out of 15 patients (40.0 %). All 6 deteriorated patients immediately recovered after SDH drainage with Trendelenburg position; 5 achieved sustained improvement without EBP and 1 required EBP. During the follow-up period, 14 out of 15 patients (93.3 %) showed good recovery.

CONCLUSIONS

Evacuation of SDH is not always necessary in SIH; however, we did not hesitate to perform hematoma drainage, in deteriorated patients or those with thick hematoma that is associated with significant sagging and cistern effacement. This can prevent irreversible neurologic complications. Moreover, the Trendelenburg position may help to achieve sustained improvement without additional treatment.

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

Continuous intrathecal saline infusion for treating refractory spontaneous intracranial hypotension: A case report

Spontaneous intracranial hypotension (SIH) is a poorly understood condition that presents with a wide variety of symptoms, ranging from mild headaches to coma. It is typically caused by continuous spontaneous leakage of spinal cerebrospinal fluid (CSF), resulting in orthostatic headaches. However, the appropriate management of refractory SIH remains unclear. A 50-year-old man presented with orthostatic headache followed by a rapid decline in mental status. The imaging findings were consistent with the diagnosis of SIH, with bilateral cerebral subdural hematomas and abnormal fluid collection in the posterior epidural space from the T2 to T12 levels. Computed tomography myelography of the whole spine revealed multiple high-flow CSF leakages at the T6 to T8 levels. Despite treatment with bilateral burr hole drainage for subdural hematomas and repeated lumbar epidural blood patch (EBP) three times, the patient's condition worsened and he developed stupor. A lumbar intrathecal saline bolus (90 ml) was administered to restore CSF depletion. The patient's verbal function improved immediately, and continuous intrathecal saline infusion was administered at a rate of 10 ml/h for two days. The patient's stupor gradually resolved, and after his symptoms improved, the EBP injection was repeated at the T8 level. The patient recovered completely, and during the six-year follow-up, there were no signs of recurrence. SIH may cause a refractory decline in mental status, and lumbar intrathecal saline infusion may help arrest or reverse an impending central (transtentorial) herniation. This case demonstrates an appropriate bolus and continuous infusion of normal saline, and documents the resolution of SIH. This maneuver may change the CSF flow pattern and aims to seal the CSF fistula. Further studies are needed to better understand the mechanism of intrathecal saline infusion and establish effective treatment strategies for refractory cases of SIH.

Sacral Dural Tears as a Cause of Spontaneous Intracranial Hypotension

PURPOSE

Dural tears at the level of the cervical, thoracic, and lumbar spine cause spontaneous intracranial hypotension (SIH) in patients with a spinal longitudinal extradural CSF collection (SLEC); however, sacral dural tears have rarely been reported so far. This study focuses on sacral dural tears as a cause of SIH.

METHODS

Retrospective data from SIH patients with confirmed sacral dural tears studied between October 2020 and November 2022 were analyzed with respect to demographic, clinical and imaging features. Digital subtraction myelography (DSM) and lumbar epidural blood patch (EBP) were modified by placing the patient in reversed Trendelenburg position.

RESULTS

Of the SIH patients, 9 (all women; mean age, 38.5 years; mean body mass index, BMI, 22.9) out of 149 had a sacral dural leak (6%) that occurred spontaneously in 7/9, while 2/9 were likely associated with minor trauma. None had a sacral fracture. The mean SIH score was 6.8. All patients showed SLEC on heavily T2-weighted MR myelography (T2-MRM), 4/9 exclusively sacral and 5/9 with partial or complete involvement of the remaining spine. 4/9 had none, but 5/9 had meningeal sacral cysts, 2/5 had large cysts/ectasia. Confirmation of the sacral origin of the leak was provided in 4/9 by T2-MRM, in 2/9 by DSM and 3/9 by CT myelography (CTM) whereas 0/9 revealed the exact site of leak within the sacrum.

CONCLUSION

Sacral dural tears should be considered as a possible cause for SIH. It is concluded to implement T2-MRM covering the entire sacrum in the standard MRI protocol and propose EBP in the reverse Trendelenburg position as a therapeutic approach.

Risk factors for recurrence of post-dural puncture headache following an epidural blood patch: a retrospective cohort study

INTRODUCTION

Post-dural puncture headache (PDPH) occurs in 0.38-6.3% of neuraxial procedures in obstetrics. Epidural blood patch (EBP) is the standard treatment but fails to provide full symptom relief in 4-29% of cases. Knowledge of the risk factors for EBP failure is limited and controversial. This study aimed to identify these risk factors.

METHODS

We performed a retrospective cohort study using electronic records of 47920 patients who underwent a neuraxial procedure between 2001 and 2018 in a large maternity hospital in Switzerland. The absence of full symptom relief and the need for further treatment was defined as an EBP failure. We performed univariate and multivariate analyses to compare patients with a successful or failed EBP.

RESULTS

We identified 212 patients requiring an EBP. Of these, 55 (25.9%) had a failed EBP. Signs and symptoms of PDPH did not differ between groups. While needle size and multiple pregnancies were risk factors in the univariate analysis, mostly those related to the performance of the EBP remained significant following adjustment. The risk of failure increased when the epidural space was deeper than 5.5 cm (OR 3.08, 95% CI 1.26 to 7.49) and decreased when the time interval between the initial dural puncture and the EBP was >48 h (OR 0.20, 95% CI 0.05 to 0.83).

CONCLUSION

Persistence of PDPH following a first EBP is not unusual. Close attention should be given to patients having their EBP performed <48 h following injury and having an epidural space located >5.5 cm depth, as these factors are associated with a failed EBP.

Late-presenting dural leak following spine fusion in the pediatric population

PURPOSE

The purpose is to describe how patients with a late-presenting dural leak (LPDL) after posterior spinal fusion (PSF) was diagnosed and treated at a single institution.

METHODS

Of the 1991 patients who underwent a PSF between 2010 and 2018, 6 patients were identified with a clinical course consistent with a potential LPDL.

RESULTS

Six patients with median age 16.9 years had onset of headache ranging 1-12 weeks postoperatively (median 6.5 weeks). All six patients presented with positional headache, and half (3/6) presented with emesis. 5/6 patients underwent contrast brain MRI, which demonstrated pachymeningeal enhancement. 4/5 patients with dural enhancement went on to have CT myelogram. Five patients had a CT myelogram, which identified a dural leak in all patients and localized the leak in four of five patients. All patients underwent an epidural blood patch, which resolved the pain in five patients. One patient without relief underwent revision surgery with removal of a medially placed screw and fibrin glue placement resolving symptoms.

CONCLUSIONS

Postoperative dural leaks associated with PSF may present in a delayed fashion. The majority of leaks were not associated with screw malposition. In diagnosing patients with suspected LPDL, we suggest brain MRI with contrast as a first step. Most patients with pachymeningeal enhancement shown on contrast brain MRI had dural leaks that were identified through CT myelograms. For patients with a dural leak, if there is no disruption from screws, a blood patch appears to be an effective treatment.

LEVEL OF EVIDENCE

IV.

Treatment of postural headache occurred 26 days after spinal pain procedure - A case report

BACKGROUND

Cerebrospinal fluid (CSF) leakage may cause intracranial hypotension and postural headache. Secondary intracranial hypotension may result from an iatrogenic dural puncture or traumatic injury associated with pain procedures.

CASE

A 45-year-old male developed a headache 26 days after spinal pain procedure. Headache was characterized as postural, worsening with standing or sitting and improving while lying down. The pain did not resolve despite the administration of oral and intravenous analgesics. A spinal magnetic resonance imaging revealed epidural venous congestion and a suspicious CSF leak around the left L4/5 level. The patient received an epidural blood patch (EBP), the headache improved dramatically, and the patient was discharged.

CONCLUSIONS

Delayed postural headaches may not be directly related to pain management. Nevertheless, intracranial hypotension related to pain management should be suspected even in this case. If confirmed, quickly applying an EBP is an effective treatment option.

Accidental dural puncture during epidural blood patch: a narrative review

Whilst performing an epidural blood patch (EBP) to treat post dural-puncture headache following accidental or intentional dural puncture, the risk of a subsequent accidental dural puncture (ADP) is commonly quoted as 1%. However, a recent review reported only three documented cases. It seems likely that this complication is more common than is acknowledged, yet there is a paucity of literature and an absence of any guidance as to how to proceed in practice. This review addresses three unanswered questions regarding ADP during EBP: what is the incidence; what are the immediate clinical consequences; and what is the optimal clinical management? The incidence may reasonably be estimated to be 0.5-1%. Even on large units, this complication will not be experienced by every consultant anaesthetist during their career. It is likely to occur 20-30 times per year in the United Kingdom, and in greater numbers in those countries with higher epidural rates. Immediately re-attempting an EBP at a different level may be a reasonable management approach which has high efficacy, and is without clear evidence of significant harm. However, the limited evidence means that the risks are poorly characterised, and more data may lead to alternative conclusions. There is uncertainty amongst obstetric anaesthetists about how to manage ADP during EBP. More data and pragmatic guidance, which evolves with further evidence, will ensure optimal care for patients suffering this compound iatrogenic complication.

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.

Gorham-Stout disease affecting the spine with cerebrospinal fluid leakage and Chiari-like tonsillar herniation: a rare case report and review of literature

BACKGROUND

Gorham-Stout disease (GSD) is a very rare disorder characterized by massive osteolysis of poorly understood aetiology. The association between GSD involving the skull base and cerebrospinal fluid (CSF) leakage has been reported in the literature. However, few cases of CSF leakage and Chiari-like tonsillar herniation in GSD involving the spine have been reported.

CASE PRESENTATION

We present the case of a 20-year-old man with GSD involving the thoracic and lumbar spine, which caused CSF leakage and Chiari-like tonsillar herniation. The patient underwent four spinal surgeries for osteolytic lesions of the spine over a 10-year period. Here, we discuss the possible aetiology of the development of CSF leakage. Epidural blood patch (EBP) was performed at the T11-T12 level to repair the CSF leakage. After EBP treatment, rebound intracranial hypertension (RIH) developed, and tonsillar herniation disappeared 2 months later.

CONCLUSIONS

GSD involving the spine with CSF leakage and Chiari-like tonsillar herniation is relatively rare. For patients who have undergone multiple spinal surgeries, minimally invasive treatment is an alternative treatment for CSF leakage. EBP can repair CSF leakage secondary to GSD and improve chronic brain sagging, with reversibility of Chiari-like malformations.

Spontaneous Intracranial Hypotension: Controversies in Treatment

Spontaneous intracranial hypotension (SIH) is a disorder of low cerebrospinal fluid (CSF) volume secondary to CSF leakage through a dural defect along the neuraxis with an estimated incidence of 5 people per 100,000.Great debate persists on the optimal treatment of this pathology, and clinical results are often contradictory. SIH may be initially approached via conservative measures, such as bed rest that is often supplemented with hydration, caffeine, and theophylline, which overall relieve symptoms in a small subset of patients at 6 months. Epidural blood patching (EBP) is generally the next consideration in symptom management. It is the most commonly performed intervention for spinal CSF leaks, as the first option or following the failure of conservative treatment. Further procedures may be performed in the case of EBP partial or temporary response and if the spinal CSF leak has been definitively localized (Beck et al., Neurology 87:1220-26, 2016). In those cases, if the CSF leak is well localized, the surgical closure of the spinal CSF leak may be considered.SIH is a complex but treatable CSF disorder. Despite recent advances in the field of neuroimaging and the different therapeutic options available, the appropriate management remains controversial and should be tailored to the patient.

[Postdural puncture headache in obstetrics : Pathogenesis, diagnostics and treatment]

Postdural puncture headache (PDPH) is one of the most important complications of peripartum neuraxial analgesia. Loss of cerebrospinal fluid volume and pressure as well as compensatory intracranial vasodilation are assumed to be responsible. Potentially severe long-term sequelae necessitate the correct diagnosis of PDPH, exclusion of relevant differential diagnoses (with atypical symptoms and when indicated via imaging techniques) and rapid initiation of effective treatment. Nonopioid analgesics, caffeine and occasionally theophylline, gabapentin and hydrocortisone are the cornerstones of pharmacological treatment, while the timely placement of an autologous epidural blood patch (EBP) represents the gold standard procedure when symptoms persist despite the use of analgesics. Procedures using neural treatment are promising alternatives, especially when an EBP is not desired by the patient or is contraindicated. Interdisciplinary and interprofessional consensus standard procedures can contribute to optimization of the clinical management of this relevant complication.

Efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension: an evidence map protocol

BACKGROUND

Spontaneous intracranial hypotension (SIH) is a debilitating disorder caused by non-iatrogenic spinal cerebrospinal fluid leaks. SIH is increasingly recognized as an important treatable cause of secondary headaches. Treatment involves either epidural blood patching or surgery, which have considerable differences in their adverse event rates, recovery times, and cost. The objective of this evidence map is to understand the breadth of studies that investigate SIH treatment efficacy and to identify knowledge gaps to inform future research.

METHODS

This review will consider experimental, observational, and systematic review studies that assess the efficacy of epidural blood patching and surgery for the treatment of patients with SIH. Individual case studies, clinical guidelines, editorials, protocols, and studies that do not assess an intervention will not be included. English language studies will be included without limitation based on the date of publication. Databases to be searched include MEDLINE® (via Ovid), EMBASE (via Elsevier), and Web of Science™ (via Clarivate). Study selection will be performed independently by two investigators with extracted data to include study type, the number of patients included, patient descriptors, intervention characteristics, and outcome measure used. Data will be presented through a narrative summary aided by tabular and graphical formats in a manner that aligns with the objective of the evidence mapping review.

DISCUSSION

The overarching goal of this evidence map is to provide an improved understanding of the breadth of studies investigating SIH treatment efficacy in the literature and to thereby identify knowledge gaps that can inform future research directions.

TRIAL REGISTRATION

OSF Registry https://osf.io/nwju7 .

Recognized and unrecognized dural punctures in 12,981 labor epidurals: an audit of management

PURPOSE

Unintentional dural puncture (DP) and post-dural puncture headache (PDPH) continue to cause discomfort and disability in a small proportion of post-partum women. We report an audit of the management of recognized and unrecognized DP over 10 years.

METHODS

Clinical data were prospectively collected for women who experienced a recognized DP or developed symptoms following a neuraxial procedure. Details were documented regarding patient characteristics, the neuraxial procedure, symptoms reported, and epidural blood patches. We reported rates of recognized DP, unrecognized DP, PDPH, and blood patches performed. Data were presented as number (percent) and proportions of interest compared using Chi square analysis.

RESULTS

Between January 2009 and December 2018, 12,981 women utilized labor epidural analgesia. A recognized DP occurred in 131 (1.0%) and an unrecognized DP in 60 (0.5%), with unrecognized DPs comprising 31% of the total. Of 131 recognized punctures, 86 (66%) developed a PDPH. A total of 146 (1.1%) women experienced a PDPH. Of those, a blood patch was performed in 93 (64%). Intrathecal catheters were inserted for > 24 h in 43 (33%) women with a recognized DP. Of those, 33 (77%) developed a PDPH, compared to 53 (60%) of those without an intrathecal catheter in situ for > 24 h (P = 0.06).

CONCLUSIONS

Rates of DP were consistent with those reported by others. Unrecognized DP comprised a third of all DP, and systematic post-neuraxial follow-up is essential to identify these women. Epidural blood patch was performed in most women experiencing symptoms of PDPH.

Recent update on epidural blood patch

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.

Epidural blood patch for spontaneous intracranial hypotension with subdural hematoma: A case report and review of literature

BACKGROUND

Cerebrospinal fluid (CSF) leakage at C1/2 in spontaneous intracranial hypotension (SIH) is rare. Subdural hematoma (SDH), a serious complication of SIH, may lead to neurological deficits. This report presents a case of SDH after spontaneous C1/2 CSF leakage, which was treated with a targeted epidural blood patch (EBP).

CASE SUMMARY

A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache, nausea, and vomiting. Brain computed tomography imaging revealed bilateral, subacute to chronic SDH. Brain magnetic resonance imaging (MRI) findings were SDH with dural enhancement in the bilateral cerebral convexity and posterior fossa and mild sagging, suggesting SIH. Although the patient underwent burr hole trephination, the patient’s orthostatic headache was aggravated. MR myelography led to a suspicion of CSF leakage at C1/2. Therefore, we performed a targeted cervical EBP using an epidural catheter under fluoroscopic guidance. At 5 d after EBP, a follow-up MR myelography revealed a decrease in the interval size of the CSF collected. Although his symptoms improved, the patient still complained of headaches; therefore, we repeated the targeted cervical EBP 6 d after the initial EBP. Subsequently, his headache had almost disappeared on the 8^th day after the repeated EBP.

CONCLUSION

Targeted EBP is an effective treatment for SDH in patients with SIH due to CSF leakage at C1/2.

Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study

BACKGROUND CONTEXT

Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence.

PURPOSE

The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique.

STUDY DESIGN/SETTING

Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded.

OUTCOME MEASURES

The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group).

METHODS

The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data.

RESULTS

Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration.

CONCLUSIONS

An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.

Risk factors for nonresponsive hydration in patients with spinal cerebrospinal fluid leakage

BACKGROUND

Spinal cerebrospinal fluid (CSF) leakage is frequently encountered clinically after lumbar puncture or spontaneous events. Although some patients recover without treatment or after intensive hydration, some require an epidural blood patch (EBP). The risks of nonresponsive hydration remain unknown. Therefore, we identified the risk factors for patients with spinal CSF leakage nonresponsive to hydration.

METHODS

We retrospectively reviewed patients diagnosed with spinal CSF leakage between January 2010 and March 2021. Clinical data, including patient age, sex, etiology, and radiological indications in magnetic resonance imaging, were compared between patients who were responsive and non-responsive to hydration.

RESULTS

Of the 74 patients with spinal CSF leakage, 25 were responsive to hydration and 49 required EBP. Patients who were nonresponsive to hydration were older (39.27 vs. 34.32 years, P = 0.01), had a higher percentage of spontaneous intracranial hypotension (93.88% vs. 68.00%, P = 0.005), had more spinal CSF leakage (12.04 vs. 8.04, P = 0.01), and had a higher percentage of dural sinus engorgement (81.63% vs. 60.00%, P = 0.044). Spontaneous intracranial hypotension (odds ratio [OR]: 4.63; 95% confidence interval [CI]: 1.00-21.38) and having ≥9 spinal CSF leakages (OR: 3.29; 95% CI: 1.08-10.01), as indicated by magnetic resonance myelography, are considered risk factors for noneffective hydration.

CONCLUSIONS

Patients with spinal CSF leakage who have spontaneous intracranial hypotension and those with ≥9 spinal CSF leakages are considered at risk for noneffective hydration. EBP should be considered early in these patients.

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.

What's New in Neuraxial Labor Analgesia

Purpose of Review

This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed.

Recent Findings

There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia.

Summary

Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 10⁶/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.

Management of an intracranial hypotension patient with diplopia as the primary symptom: A case report

BACKGROUND

Intracranial hypotension (IH) is a disorder involving cerebrospinal fluid (CSF) hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed, especially in these patients without the prototypical manifestation of an orthostatic headache. At present, the management of IH with both cranial nerve VI palsy and bilateral subdural hematomas (SDHs) is still unclear.

CASE SUMMARY

A 67-year-old male Chinese patient complained of diplopia on the left side for one and a half mo. Computed tomography revealed bilateral SDHs and a midline shift. However, neurotrophic drugs were not effective, and 3 d after admission, he developed a non-orthostatic headache and neck stiffness. Enhanced magnetic resonance imaging revealed dural enhancement as an additional feature, and IH was suspected. Magnetic resonance myelography was then adopted and showed CSF leakage at multiple sites in the spine, confirming the diagnosis of having IH. The patient fully recovered following multiple targeted epidural blood patch (EBP) procedures.

CONCLUSION

IH is a rare disease, and to the best of our knowledge, IH with diplopia as its initial and primary symptom has never been reported. In this study, we also elucidated that it could be safe and effective to treat IH patients with associated cranial nerve VI palsy and bilateral SDHs using repeated EBP therapy.

Comparisons of clinical characteristics, brain MRI findings, and responses to epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache: retrospective study

BACKGROUND

Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment.

METHODS

We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus).

RESULTS

A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02).

CONCLUSIONS

Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch

BACKGROUND

Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid leak and pseudomeningocele if unrecognized or incompletely repaired. We describe the use of ultrasound to visualize the site of durotomy, observe the aspiration of the pseudomeningocele, and guide the precise application of an ultrasound-guided epidural blood patch (US-EBP), under direct visualization in real time.

METHODS

A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele.

RESULTS

Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and body mass index were 60.5 (±12.6) years and 27.8 (±4.50) kg/m², respectively. The most frequent index operation was laminectomy (24.5%), and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (interquartile range 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases, and the median clinical follow-up was 4.3 (interquartile range 2.4-14.5) months.

CONCLUSIONS

This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele. The success rate suggests that routine utilization of US-guided EBP may allow for targeted treatment of pseudomeningoceles, without the prolonged hospitalization associated with lumbar drains or the risks of general anesthesia and impaired wound healing associated with surgical revision.

It.ÇÖs not always postdural puncture headache: a case report and note to the astute anesthesiologist

Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.

CT-Guided Autologous Blood Patch for High-Level Cervical Cerebrospinal Fluid Leakage: Imaging Characteristics and Treatment Safety and Efficiency

INTRODUCTION

Epidural blood patches (EBPs) are rarely performed at the high-level cervical levels. The aim of the study was to investigate the imaging features, safety, and effectiveness of CT-guided percutaneous EBPs for high-level cervical cerebrospinal fluid (CSF) leakage.

METHODS

Twenty-five patients with spontaneous high-level (C1-C3) CSF leakage on MRI and CT imaging, including 2 patients with intracranial epidural hematoma caused by CSF, were treated with EBP. Two needles were inserted into the C1-3 bilateral epidural space. The needle location was confirmed by injection of both 3-5mL sterile air and a diluted iodinated contrast agent to delineate its spatial diffusion. The patient's blood 11.1 ± 3.1 mL was slowly injected to make a patch; the distribution in epidural space was monitored with intermittent CT scanning.

RESULTS

The typical manifestation of CSF leakage was the high signal outside the C1-3 cervical dura on MR T2W fat inhibition images and low density in cervical muscle space on CT images. Twenty patients suffered from headaches and were able to sit and walk 24 h after the operation. Four patients, with partial relief of headache and a small but persistent CSF leakage, were re-treated with EBS. One patient underwent a third operation because of a persistent CSF leakage on MRI.

CONCLUSIONS

Imaging of water at the surrounding epidural space of high cervical level is a typical feature of dural rupture on both MRI and CT. CT-guided EBP is safe and efficient for the high-level cervical CSF leakage, especially for cases in which conservative treatments failed.

Cerebral venous thrombosis in spontaneous intracranial hypotension: A report of 8 cases and review of the literature

BACKGROUND

The occurrence of cerebral venous thrombosis (CVT) in patients with spontaneous intracranial hypotension (SIH) raises difficult practical questions regarding the management of the two conditions. The first-line therapy for CVT is anticoagulation (AC); however, its potential benefit in SIH/CVT patients, especially if complicated by subdural haematoma, must be carefully evaluated taking account of the intracranial haemorrhage risk. Venous system recanalization and good prognosis in SIH/CVT patients treated with epidural blood patch (EBP), the main treatment option for SIH, have been already described.

METHODS

We reviewed our cases of SIH complicated by CVT among a cohort of 445 SIH patients observed and treated during the last years. All published case reports and case series reporting patients with SIH and CVT were also ascertained and reviewed.

RESULTS

Eight (2%) out of 445 patients suffering with SIH, were also diagnosed with CVT. All patients observed had orthostatic headache, three of them experienced a change in their headache pattern over the SIH course. Six out of eight patients received both AC and EBP treatments. Two patients were treated using only AC or EBP. A bilateral subdural haematoma enlargement after 1 month of AC was observed in one case. Complete CVT recanalization after treatment was obtained in three patients, including two with multiple CVT at baseline; partial CVT recanalization was achieved in two patients. Three patients experienced no CVT recanalization. After 6-48 months' follow-up all patients were still asymptomatic.

CONCLUSIONS

The use of AC therapy should be weighed against the intracranial haemorrage risk and should be monitored carefully if initiated. Effective and prompt EBP, even without AC therapy, might lead to a good prognosis in selected cases.

Low-pressure CSF shunt malfunction without preceding lumbar puncture treated by epidural blood patch: report of 2 cases

Low-pressure CSF shunt malfunction is a poorly understood complication of hydrocephalus affecting patients of all ages. Treatment commonly requires external drainage of CSF to subatmospheric pressures for days to weeks in an intensive care setting. The current communication describes the repurposing of an established therapeutic technique, epidural blood patch, for successful initial management in 2 cases of low-pressure shunt malfunction in the absence of a recognized spinal CSF fistula. This technique may shorten length of stay and obviate potential morbidity in the management of what is otherwise a vexatious clinical problem.

Long-term telemetric intracerebral pressure monitoring as a tool in intracranial hypotension

Intracranial hypotension (IH) remains a difficult neurosurgical diagnosis. Relying solely on the symptomatology may be misleading for both diagnosis and assessment of treatment effect as symptoms may resemble other conditions not related to IH. As such, paraclinical supplements in both diagnosis and treatment follow-up are warranted. We present a 42-year-old male with IH treated with computed tomography-guided epidural blood patch. The diagnosis and treatment assessment included continual intracerebral pressure (ICP) monitoring. We found ICP monitoring helpful in IH diagnosis and long-term assessment of treatment and propose this modality as a supplement in difficult IH cases.

A systematic review and meta-analysis of factors affecting the outcome of the epidural blood patching in spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is an often misdiagnosed condition resulting from non-iatrogenic cerebrospinal fluid (CSF) hypovolemia, typically secondary to spinal CSF leakage. Patients commonly present with posture-related headache, nausea, and vomiting. Following failure of conservative measures, epidural blood patching (EBP) is the most commonly performed intervention for spinal CSF leaks. The authors performed a systematic review and meta-analysis of existing literature to evaluate the role of different factors possibly affecting the efficacy of the EBP procedure. In accordance with the PRISMA guidelines, PubMed/Medline and SCOPUS databases were searched. Six eligible articles were retrieved. Five hundred patients were treated for SIH with EBP, of which 300 reported good response defined as complete remission of symptoms within 48 h after the first EBP requiring no further invasive treatment. Among the factors available for meta-analysis, none was found to be statistically significant in affecting the efficacy of the EBP procedure. A largely symmetrical funnel plot is reported for all the variables evaluated, indicating that publication bias did not play a significant role in the observed effects. The current knowledge about SIH and the EBP is scarce. The existing literature is contradictory and insufficient to aid in clinical practice. More studies are needed to draw significant conclusions that may help in the identification of patients at higher risk of EBP failure, who may benefit from different approaches.

Temporal trends in the incidence of post-dural puncture headache following labor neuraxial analgesia in the United States, 2006 to 2015

BACKGROUND

Labor neuraxial analgesia utilization has increased in the United States (U.S.) but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics.

METHODS

Data for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006-2015, a U.S. 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into (1) PDPH coded without epidural blood patch (EBP), and (2) PDPH coded with EBP. Temporal trends in incidence were described using the percent change between 2006 and 2015 and its 95% confidence interval (CI).

RESULTS

Of the 29 011 472 deliveries studied, 86 558 (29.8 per 10 000; 95% CI: 29.3 to 30.2) recorded a diagnosis of PDPH, including 34 019 without EBP (11.7 per 10 000; 95% CI 11.4 to 12.0) and 52 539 with EBP (18.1 per 10 000; 95% CI 17.8 to 18.4). A significant decrease in the incidence of PDPH was observed from 31.5 per 10 000 in 2006 to 29.2 per 10 000 in 2015 (-7.5%; 95% CI -2.2 to -0.5; P=0.001). The decrease in the incidence of PDPH was significant irrespective of the presence of EBP. The decrease was observed in the three categories of hospitals examined (rural, urban non-teaching, and urban teaching).

CONCLUSIONS

During the study period, the reported incidence of PDPH in the U.S. has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity.

Delayed recurrence of spontaneous intracranial hypotension syndrome mimicking a Chiari I malformation: Case report with a review of the literature

INTRODUCTION

Cerebellar tonsils descent seen on brain MRI is, along with other findings, a recognized radiological sign of possible spontaneous intracranial hypotension (SIH). The short-term outcome of SIH is usually favorable with symptoms improvement and reversibility of the low-lying tonsils. Nevertheless, data on the long-term outcome are lacking or inconsistent.

CASE REPORT

A 32-year-old woman presented to her general practitioner with a six months history of non-specific headaches. An MRI brain with gadolinium showed a 12mm tonsillar descent with no other remarkable findings. Headaches were initially managed conservatively as migraines. Following the onset of progressive upper back and shoulder pain at rest, nausea, photophobia and fogging in her vision, the patient was referred to our Department with a suspicion of symptomatic Chiari I malformation. After an in-depth anamnesis, it emerged a previous history of SIH, 14 years earlier, successfully treated conservatively in another center. A whole spine MRI confirmed the suspicion of recurrent SIH showing an anterior cervico-thoracic epidural fluid collection. The patient underwent an epidural blood patch with complete resolution of the symptoms and radiological signs.

DISCUSSION

To our knowledge, this case is the first report of delayed recurrence of a SIH successfully treated conservatively over 10 years earlier. The etiopathogenesis and management of this rarity with literature review is discussed.

CONCLUSION

An isolated cerebellar tonsil descent with no other remarkable findings on brain MRI and a previous history of SIH should always alert the clinician of a possible late recurrence of a CSF leak and avoid unnecessary Chiari I malformation surgical procedures.

Misdiagnosis of Spontaneous Intracranial Hypotension Presenting as Acute Mental Deterioration Caused by Unilateral Acute Subdural Hematoma: Case Report

Spontaneous intracranial hypotension (SIH) is usually a benign disease which mostly present as orthostatic headache and resolves by conservative treatment or epidural blood patch. However, in severe cases large subdural hematoma or brain caudal herniation can progress to brain herniation and neurologic complications. We introduce a rare case of SIH which presented as acute mental deterioration with unilateral acute subdural hematoma. A 60 years old female visited to emergency room for stuporous mental change and unilateral acute subdural hematoma. Decompressive craniectomy and hematoma removal was performed to release brain herniation and increased intracranial pressure. There was temporary improvement of consciousness, but sustained leakage of cerebrospinal fluid (CSF) and caudal brain herniation worsened patient's condition. After recognizing that CSF leakage and hypovolemia was the underlying disease, emergent epidural blood patch and early cranioplasty was performed. After treatment CSF volume was normalized and patient recovered completely without neurologic deficits. Acute mental deterioration with unilateral subdural hematoma is a rare presentation for SIH. Treatment strategy for subdural hematoma with concomitant SIH patients, should be planned carefully with concerns to CSF hypovolemia and intracranial pressure.

[Self-applied sphenopalatine ganglion block for postdural puncture headache: four case reports]

BACKGROUND AND OBJECTIVES

The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management.

CASE REPORT

This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity.

CONCLUSION

The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.

The algorithm for diagnosis and management of intracranial hypotension with coma: Report of two cases

Background:

Spontaneous intracranial hypotension (SIH) is caused by spontaneous cerebrospinal fluid (CSF) leaks that can be treated in most cases with an epidural blood patch (EBP). However, some patients, who develop severe brain sagging, can neurologically deteriorate, and in occasional instances, which become comatose. Here, with the presentation of two cases, and a review of the literature, we have set guidelines for diagnosing SIH along with recommendations for its management.

Case Description:

We reviewed two cases of SIH. Both patients became comatose due to a CSF leak associated with a tear in the spinal dura diagnosed on myelo-CT studies. As targeted EBP failed to achieve sustained improvement, direct operative repair of the dural tears was warranted (video presentation).

Conclusion:

After reviewing two cases of SIH and the literature, we developed an algorithm for the diagnosis and management of SIH. To avoid deterioration to a comatose status, we recommend the early performance of myelo- CT studies to identify the location of the dural leak, followed by early dural repair.

The domino effect of acephalgic spontaneous intracranial hypotension

Spontaneous intracranial hypotension results from a spinal CSF leak and usually presents with orthostatic headache, although acephalgic presentations have anecdotally been reported. The underlying low CSF volume, rarely, leads to serious complications such as cerebral venous thrombosis and coma. We report a patient presenting with cerebral venous thrombosis secondary to acephalgic spontaneous intracranial hypotension. An epidural blood patch was performed; nonetheless, the patient intracracal condition deteriorated to coma and neuroimages showed a deep brain swelling with midbrain distortion, subsequently complicated by intracranial pontine hemorrhage.

Tonic-clonic seizure after unrecognized unintentional dural puncture

Patients who suffer an unintentional dural puncture have a high risk of developing a post-dural puncture headache. Other neurologic complications have been reported, but seizure is rarely seen. We present a case of a 21-year-old primigravida who experienced an unrecognized unintentional dural puncture that ultimately resulted in a tonic-clonic seizure from intracranial hypotension one week following the dural breach. Her trachea was intubated and she was transferred to the intensive care unit. Two epidural blood patches, performed by neuroradiologists, were needed before the patient experienced complete resolution of her headache. During the re-admission, she also experienced a pulmonary embolus which further lengthened her hospital stay.

Spontaneous intracranial hypotension associated with cerebral venous thrombosis detected by a sudden seizure: a case report

Background

Spontaneous intracranial hypotension (SIH) is rare but can lead to life-threatening complications including cerebral venous thrombosis (CVT). The concurrence of CVT and SIH raises questions regarding priority.

Case presentation

We present the case of a 52-year-old woman who developed sudden left-sided hemiparesis and generalized tonic-clonic seizures. She experienced progressive orthostatic headaches over the prior 2 weeks. Imaging showed thrombosis in the left transverse and sigmoid sinuses, bilateral subdural hematomas, and a cervicothoracic cerebrospinal fluid leak. Low molecular weight heparin was administered, but it was discontinued 2 days later due to subarachnoid hemorrhage. She was transferred to our hospital where an epidural blood patch was applied immediately, which resulted in complete symptom relief.

Conclusion

CVT is a rare complication of SIH that may result in devastating consequences. Treatment of SIH should be the primary focus. Prompt diagnosis and EBP application can result in a good outcome.

Percutaneous CT-guided epidural fibrin sealant injection for refractory pediatric post-dural puncture headache

Post-dural puncture headache is an uncommon entity in young children and adolescents. Percutaneous epidural blood patching has been classically used to manage refractory post-dural puncture headaches. Injectable fibrin sealant has been shown in a few adult cases to relieve symptoms where blood patching has either failed or was not appropriate. We report a 10-year-old boy who experienced rapid relief of post-dural puncture headache symptoms following percutaneous lumbar epidural fibrin sealant injection under computed tomography guidance. Percutaneous epidural fibrin sealant injection may be an acceptable treatment for post-dural puncture headaches refractory to epidural blood patching, or when an epidural blood patch is otherwise contraindicated. The pediatric interventional radiologist should be aware of this off-label use of fibrin sealant.

Headache and Dural Enhancement: Two Case Studies of Different Treatable Pathologies

BACKGROUND

Hypertrophic pachymeningitis (HP) and spontaneous intracranial hypotension are different treatable diseases, which should promptly be recognized and treated to prevent neurologic sequelae. Headache and dural enhancement are the main features of both diseases, thus differentiating between these 2 conditions can be difficult.

CASES DESCRIPTION

We present 2 cases with headache and dural enhancement, in which the differential diagnosis was challenging at presentation because, in both cases, clear positional pain modification was not reported. Each patient was referred to us with the suspicion of a diagnosis actually affecting the other one. Based on further findings, which supported diagnosis of spontaneous intracranial hypotension in the first case and of HP in the second one, we briefly review clinical, radiologic, and laboratory features, which can help in the differential diagnosis.

CONCLUSIONS

An accurate diagnostic workup is mandatory to distinguish among HP and intracranial hypotension.

Acute Deterioration in a Patient with Bilateral Chronic Subdural Hematomas Associated with Intracranial Hypotension Treated with an Epidural Blood Patch

BACKGROUND

Intracranial hypotension due to cerebrospinal fluid (CSF) leak is often associated with secondary chronic subdural hematoma (CSDH). Although epidural blood patch (EBP) treatment for the CSF leak site has been reported to result in spontaneous regression of the CSDH in most cases, it is still debatable whether blocking CSF leak first in the patients with intracranial hematoma is always safe.

CASE DESCRIPTION

A 72-year-old woman presented with orthostatic headache after a head injury and was diagnosed with intracranial hypotension. Computed tomography myelography and radioisotope cisternography failed to reveal the CSF leak point. The overflow leak test, a novel diagnostic method for intracranial hypotension, revealed a leakage at the cervical spine. Bilateral CSDHs were also observed by a computed tomography scan of the head. We performed EBP at the cervical spine and anticipated subsequent regression of the CSDH by normalizing intrathecal pressure. However, the patient became delirious the morning after EBP, and an emergency burr hole trepanation was performed. The patient's consciousness fully recovered, and her orthostatic headache improved as well.

CONCLUSIONS

This case presentation demonstrated that in the case of intracranial hypotension with secondary CSDH, performing EBP and waiting for subsequent spontaneous regression of CSDH are not necessarily safe. Immediate burr hole trepanation should be prepared for the subsequent rapid symptomatic change of the CSDH after EBP.

Pterygopalatine Ganglion Block as a Rescue Technique for Failed Epidural Blood Patch

Placement of an epidural blood patch is the gold standard treatment for a postdural puncture headache when conservative measures have failed. If unsuccessful in relieving the symptoms, a second epidural blood patch may be warranted. However, when the accepted gold standard treatment has failed, alternative therapies may be pursued. A pterygopalatine ganglion block has been shown to be effective as an alternative to epidural blood patch placement. This case demonstrates the use of a suprazygomatic pterygopalatine ganglion block as a rescue technique for failed repeated epidural blood patch, with complete and permanent resolution of the headache.

Intrathecal blood injection: a case report of a rare complication of an epidural blood patch

Background

Intrathecal injection is a rare complication of spinal anesthesia and an underreported complication of epidural blood patches. Although there are other reported cases of intrathecal blood injection, these cases lack confirmatory imaging and others report injection of mixed blood with other agents.

Case presentation

We present a case report of post-laminectomy cerebrospinal fluid leak who underwent epidural blood patch placement. CT and MRI brain imaging was obtained, depicting intrathecal blood products. The patient had subsequent seizures and respiratory distress, received supportive care, and returned to baseline after several days.

Conclusion

The patient’s clinical course illustrates the potential complications of blood products within CSF, including seizures and respiratory distress, which improved with supportive care in this case. Importantly, to our knowledge, this is the only report that clearly depicts injection of purely blood products, without other confounding agents (such as gadolinium), into intrathecal space and with diffuse spread through the CSF as visualized on CT and MRI imaging.

Surgical Management of Symptomatic Boxing-Induced Spinal Cerebrospinal Fluid Leak After Failed Epidural Blood Patch

BACKGROUND

Spontaneous spinal cerebrospinal fluid (CSF) leak is an increasingly recognized condition responsible for spontaneous intracranial hypotension. A host of connective tissue disorders and mechanical factors may precipitate the condition. Conservative treatment has limited efficacy, and many patients with persistent symptoms ultimately require epidural blood patch (EBP). However, about 23%-44% of patients experience recurrence of symptoms after EBP. Unidentified or multiple sites of CSF leaks are thought to be responsible for the failure of EBP. Using our previously published technique, we treated a patient who developed a large spontaneous CSF leak in her cervicothoracic spine after a boxing class, offering further evidence of the utility of the technique for select patients.

CASE DESCRIPTION

A 28-year-old woman was referred to our center with recurrent, severe headaches and associated nausea and vomiting. She underwent EBP 3 times with no resolution of her symptoms. A right-side partial C7-T1 hemilaminotomy was performed to identify a large meningocele filled with CSF. After dissection, dural sealant was applied using an angled needle with a syringe to buttress the meningocele to allow for normalization of the hydrostatic pressure. At 5-month follow-up, her symptoms have resolved with no headaches and paresthesias in upper limbs.

CONCLUSIONS

Commonplace events, such as a boxing/sparring class, may precipitate a spontaneous spinal CSF leak. Our minimally invasive surgical approach can be safely used in patients with spontaneous intracranial hypotension with recurrent symptoms, no identified leak site, and prior failed attempts of EBP.

Spontaneous intracranial hypotension: review and expert opinion

Spontaneous intracranial hypotension (SIH) results from spinal cerebrospinal fluid (CSF) leaking. An underlying connective tissue disorder that predisposes to weakness of the dura is implicated in spontaneous spinal CSF leaks. During the last decades, a much larger number of spontaneous cases are identified and a far broader clinical SIH spectrum is recognized. Orthostatic headache is the main presentation symptom of SIH; some patients also have other manifestations, mainly cochlear-vestibular signs and symptoms. Differential diagnosis with other syndromes presenting with orthostatic headache is crucial. Brain CT, brain MR, spine MRI, and MRI myelography are the imaging modalities of first choice for SIH diagnosis. Invasive imaging techniques, such as myelography, CT myelography, and radioisotopic cisternography, are progressively being abandoned. No randomized clinical trials have assessed the treatment of SIH. In a minority of cases, SIH resolved spontaneously or with only conservative treatment. If orthostatic headache persists after conservative treatment, a lumbar epidural blood patch (EBP) without previous leak identification (so-called "blind" EBP) is a widely used initial intervention and may be repeated several times. If EBPs fail, after the CSF leak sites identification using invasive imaging techniques, other therapeutic approaches include: a targeted epidural patch, surgical reduction of dural sac volume, or direct surgical closure. The prognosis is generally good after intervention, but serious complications may occur. More research is needed to better understand SIH pathophysiology to refine imaging modalities and treatment approaches and to evaluate clinical outcomes.

Post Dural Puncture Headache, Managed with Epidural Blood Patch, Is Associated with Subsequent Chronic Low Back Pain in Patients: a Pilot Study

PURPOSE OF REVIEW

Post dural puncture headache (PDPH) is a relatively common complication which may occur in the setting of inadvertent dural puncture (DP) during labor epidural analgesia and during intentional DP during spinal anesthetic placement or diagnostic lumbar puncture. Few publications have established the long-term safety of an epidural blood patch (EBP) for the treatment of a PDPH.

RECENT FINDINGS

The aim of this pilot study was to examine the association of chronic low back pain (LBP) in patients who experienced a PDPH following labor analgesia and were treated with an EBP. A total of 146 patients were contacted and completed a survey questionnaire via telephone. The EBP group was found to be more likely to have chronic LBP (percentage difference 20% [95% CI 6-33%], RR 2.6 [95% CI 1.3-5.2]) and also LBP < 6 (percentage difference 24% [95% CI 9- 37%], RR 2.3 [95% CI 1.3-4.1]). There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Our findings suggest that PDPH treated with an EBP is associated with an increased prevalence of subsequent low back pain in parturients. The findings of this pilot study should spur further prospective research into identifying potential associations between DP, EBP, and chronic low back pain.