Spontaneous Intracranial Hypotension and Subdural Hematomas Treatment Management Using MMA Embolization and Target Blood Patch: A Case Report

We report a patient suffering from spontaneous intracranial hypotension (SIH) who, following a non-selective lumbar blood patch, returned to his healthcare provider with severe symptoms of neurological deficits. It was subsequently discovered that the aforementioned deficits were due to a bilateral subdural hematoma, and an emergency surgical drainage of the hematoma has been performed. However, the hematoma reformed and potential cerebrospinal fluid leakage was consequently investigated through myelography. Following the diagnostic finding of a venous diverticulum, a selective blood patch was executed in the affected area, and in order to stabilize the hematoma, an embolization of the middle meningeal arteries was performed. The combination of such operations allowed for the resorption of the hematoma and the improvement of neurological symptoms.

Postoperative CSF Leak: Blood Patch-A New Avenue

Introduction  Cerebrospinal fluid leak (CSF) after a neurosurgical procedure is a known complication that may result in bad outcomes (1). The incidence of CSF leak varies based on the site involved; it ranges from 4 to 32% for transsphenoidal to posterior fossa procedures. The costs involved in treating postoperative CSF leaks increases exponentially that becomes a barrier in continuing optimum treatment. There are many studies that compare the different treatment modalities and even use of sealing agents but none give an algorithm of management. Our study aims at known technique that can help to treat these kinds of low-pressure CSF leaks. Materials and Methods  This was a prospective study done over a period of 5 years from January 2014 to January 2019. All patients who underwent procedures in which durotomy was done were included in the study. Results  A total of six patients were enrolled for the study. The duration of the study spanned 5 years from January 2014 to January 2019. All the patients after taking informed consent underwent the necessary investigations and a blood patch was done. Five of the patients the CSF stopped but in one patient it persisted. This patient again underwent investigation and under image guidance another blood patch was put after which the CSF leak stopped. Conclusion  Blood patch under imaging guidance is a safe and simple technique. The success rates of cessation of CSF leaks are good. Also, it is a cost-effective method using an autograft (patient's blood).

Recurrent Spontaneous Intracranial Hypotension (SIH) and the Durability of Repeat Epidural Blood Patch (EBP)

OBJECTIVE

Spontaneous intracranial hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) of the dural sac is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate the recent efficacy and outcomes of EBP for SIH at our institution.

METHODS

Twenty-three patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018 at the same institution. All patients underwent brain MRI with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBP was placed one or two vertebral levels below areas of suspected leak, while the patient was positioned in the lateral decubitus position. Patients were seen in the outpatient setting within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 months following clinical relief of symptoms.

RESULTS

22/23 (95.7%) patients presented with complaints of orthostatic headache, and 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningeal enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had a subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, and 5/23 (21.7%) patients received further EBPs for persistent disease with all achieving relief after repeat EBP. 5/12 (41.7%) of patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient were 21.7 mL (median 20 mL, 7-40 mL) and 3.54 (median 1, 1-13) respectively. There was one complication from initial EBP (cervical dural tear requiring operative closure) treated with open surgical management successfully. In total, 18/23 (78.2%) patients are currently asymptomatic with regard to their SIH. The mean follow-up in this cohort was 2.6 years (median 1.8 years, 1.8 months-9.27 years).

CONCLUSIONS

EBP is a viable and effective option for the treatment of recurrent SIH caused by cerebrospinal fluid (CSF) leaks.

Treatment of dural tear with nerve root herniation after unilateral biportal endoscopic decompression using an epidural blood patch: a case report

We present a case of a dural tear associated with nerve root herniation following unilateral biportal endoscopic decompression (UBED) that was successfully treated using a computed tomography-guided epidural blood patch. A 60-year-old man underwent UBED for radicular pain because of spinal stenosis at L4-5. A left partial hemilaminectomy and flavectomy were performed; however, the left dorsolateral side dura mater was torn during the procedure. TachoComb® was applied at the dural tear site, and the pain was relieved following UBED. However, 3 weeks post-UBED, the patient reported severe pain with an electric shock-like sensation in the left buttock and posterior thigh region with no other neurologic symptoms. The pain was aggravated by standing and spinal motion. Follow-up lumbar spinal magnetic resonance imaging was performed. Axial images indicated protrusion of the left S2 nerve root through the left dorsolateral side of the dura mater. The patient was further diagnosed with nerve root herniation following a dura mater tear. A computed tomography-guided epidural blood patch was performed, with successful therapeutic results. The outcome of this study indicates that a small dural tear that occurs during minimally invasive spinal surgery can be efficiently treated using an epidural blood patch prior to open surgery.

TEN-YEAR FOLLOW-UP OF QUALITY IN REGIONAL ANESTHESIA AND ANALGESIA IN OBSTETRICS OBSTETRIC REGIONAL ANESTHESIA: IMPROVING QUALITY

Introduction

Quality assessment of provided healthcare is becoming a standard in numerous health institutions worldwide, which is beneficial for both the patient and the institution. In order to achieve this standard, it is necessary to develop quality indicators in all segments of healthcare. Postdural puncture headache is a common complication following neuraxial blocks, especially in obstetric anesthesia. If severe, it is a cause of emotional and psychological distress and must be treated by a blood patch.

Aim

The aim of this study was to determine whether the number of these complications is reduced when blood patch frequency is monitored and analyzed and to assess the effect of countermeasures in order to improve the quality and safety of regional anesthesia in obstetrics.

Methods

Before 2009 and during that year at the University Hospital Sveti Duh, there had been a large number of severe postdural puncture headaches after spinal anesthesia and epidural analgesia treated by a blood patch in 6.12% of cases. After noticing the rising number of blood patches, we decided to analyses data every year. We recorded all blood patches injected to obstetric patients within the period of nine year, from 2009 to 2018 and concurrently we introduced a set of measures to improve the quality of neuraxial blocks, such as the use of atraumatic 26 or 27-gauge pencil-point spinal needles and modern neuraxial blockade protocols. Data were collected from anesthesiology and gynecology protocols and analyzed with MedCalc software, version 18.1.2.

Results

The frequency of blood patch applications has been reduced from 6.12% to 0.30%, which is statistically significant. The percentage of placed epidural catheters for vaginal birth increased from 21% in 2009 to 38% in 2018. Although not statistically significant, the number of pregnant women undergoing a caesarean section is also growing, while the total number of births is falling. The proportion of cesarean sections in spinal anesthesia varies from year to year.

Discussion

A statistically significant decrease in the number of installed blood patches clearly indicates the positive effect of measures taken to improve quality, which could contribute to the growing interest of pregnant women in childbirth in epidural analgesia. The number of placed epidural catheters is increasing despite the decline in the total number of deliveries and the increase in the number of deliveries completed by cesarean section.

Conclusion

Monitoring the incidence of severe post-puncture headaches treated with blood patches has shown great progress in improving the quality and safety of regional anesthesia and analgesia in our institution, so we believe that monitoring the number of blood patches could serve as an indicator of regional anesthesia and analgesia in obstetrics. Monitoring the number of blood patches shows that the frequency of post-puncture headaches does not correlate only with the type of needle or epidural catheter used for neuroaxial blocks, but is also a sensitive indicator of any deviations from the achieved standards. Furthermore, it indicates the need for careful analysis of causes in order to adopt and implement appropriate countermeasures.

Bronchoscopic Intra-Pleural Instillation of Fibrin Glue and Autologous Blood to Manage Persistent Air Leaks after Lung Resection

Background: Persistent air leak is a common complication after lung resection causing prolonged length of stay and increased healthcare costs. Surgical intervention can be an option, but other more conservative approaches should be considered first. Here, we describe the use of flexible bronchoscopy to apply fibrin glue and autologous blood sequentially to the damaged lung. We named the technique “flexible thoracoscopy”. Methods: Medical records from patients with persistent air leaks after lung resection were collected retrospectively. Depending on the type of aerostasis that was performed, two groups were created: flexible thoracoscopy and surgery (thoracotomy). Flexible thoracoscopy was introduced at our institution in 2013. We entered the pleural space with a bronchoscope following the same surgical pathway that was used for tube thoracostomy. Perioperative characteristics and outcomes were analyzed using R software (ver. 3.4.4). Results: From 1997 to 2021, a total of 23 patients required an intervention for persistent air leaks. Aerostasis was performed via flexible thoracoscopy in seventeen patients (69%) and via thoracotomy in six patients (31%). The median age was 70 years (22–82). Twenty patients were males (87%). There was no difference in age, sex distribution, BMI, comorbidities and FEV1%. An ASA score of 3 was more represented in the flexible thoracoscopy group; however, no evidence of a difference was found when compared to the thoracotomy group (p = 0.124). Length of in-hospital stay and chest tube duration was also similar between groups (p = 1 and p = 0.68, respectively). Conclusions: Aerostasis achieved either by flexible thoracoscopy or by thoracotomy showed similar results. We believe that flexible thoracoscopy could be a valid alternative to facilitate minimally invasive treatments for persistent air leaks. Further studies are needed to confirm these results.

First-line steroid treatment for spontaneous intracranial hypotension

Background

Spontaneous intracranial hypotension (SIH) is a syndrome characterized by low cerebrospinal fluid (CSF) pressure and postural headaches, and affects 1 per 20,000 individuals every year.

Case report

We report an otherwise healthy 38‐year‐old man admitted to the hospital with orthostatic headache that developed 48 h after a short‐haul flight during which he sustained a neck injury due to turbulence. Neurological examination, blood analysis and computed tomography scan performed at the emergency service were normal. Brain and spine magnetic resonance imaging (MRI) showed diffuse pachymeningeal enhancement and contrast medium egress from the subarachnoid space into the epidural space at the level of C2. The patient was treated with bed rest, hydration and 1 mg/kg/day oral prednisone for 5 days, with a gradual withdrawal in the following 7 days. Complete symptomatic relief was observed after 16 days, with resolution of the pathological findings on brain and spinal MRI after 1 month, except for localized pachymeningeal enhancement. Clinical relief was maintained over time until last follow‐up visit 9 months later.

Conclusion

Successful conservative treatment barely exceeds one quarter of cases of SIH. The clinical benefits of steroids may result from several mechanisms of action, for example, improving brain oedema and inflammation, determining fluid retention, and facilitating reabsorption of the CSF from extradural space. Notwithstanding that epidural blood patch remains the most successful treatment for SIH, future studies should explore the effectiveness of steroids as first‐line therapy in addition to the most commonly suggested measures of bed rest and hydration.

Resolution of large pelvic lymphocele after incidental intracystic hemorrhage caused by percutaneous catheter drainage: Case report

We report the case of a large pelvic lymphocele after an ovarian cancer operation, which incidentally vanished after bleeding resulting from percutaneous catheter drainage. The patient was a 74‐year‐old woman with stage IVB ovarian cancer who underwent surgery including pelvic lymph node dissection. Three months after surgery, computed tomography revealed a large (13‐cm diameter) pelvic lymphocele with associated bilateral hydronephrosis and left femoral vein thrombosis. The lymphocele was repeatedly drained by percutaneous aspiration, and the day after the second procedure, the drainage fluid became bloody. The catheter was clamped for 3 days and then removed. The lymphocele volume gradually decreased, and it was not seen on a computed tomography scan 70 days after drainage. The lymphocele did not recur prior to her death. In this case, the intracystic hemorrhage was considered to have served as a blood patch for lymph leakage.

Autologous blood pleurodesis for the treatment of postoperative air leaks. A systematic review and meta-analysis

Background

Postoperative air leaks are a common complication after lung surgery. They are associated with prolonged hospital stay, increased postoperative pain and treatment costs. The treatment of prolonged air leaks remains controversial. Several treatments have been proposed including different types of sealants, chemical pleurodesis, or early surgical intervention. The aim of this review was to analyze the impact of autologous blood pleurodesis in a systematic way.

Methods

A systematic review of the literature was conducted until July 2020. Studies with more than five adult patients undergoing lung resections were included. Studies in patients receiving blood pleurodesis for pneumothorax were excluded. The search strategy included proper combinations of the MeSH terms “air leak”, “blood transfusion” and “lung surgery”.

Results

Ten studies with a total of 198 patients were included in the analysis. The pooled success rate for sealing the air leak within 48 h of the blood pleurodesis was 83.7% (95% CI: 75.7; 90.3). The pooled incidence of the post‐interventional empyema was 1.5%, with a pooled incidence of post‐interventional fever of 8.6%.

Conclusions

Current evidence supports the idea that autologous blood pleurodesis leads to a faster healing of postoperative air leaks than conservative treatment. The complication rate is very low. Formal recommendations on how to perform the procedure are not possible with the current evidence. A randomized controlled trial in the modern era is necessary to confirm the benefits.

Ultrasound-guided autologous blood patch - A novel modality for broncho-pleural-cutaneous fistula closure

We present a 36-year-old immuno-compromised male with non-resolving pneumonia, who developed a broncho-pleuro-cutaneous fistula following a thoracoscopic biopsy, which was successfully managed with an ultrasound-guided blood patch placed over the bronchial defect. We discuss the mechanism by which this is presumed to close a fistula, thus justifying it as a cost effective and minimally invasive modality of treatment.

Post-dural puncture headache following lumbar spinal drain: an atypical presentation with cognitive symptoms

Post‐dural puncture headache is a consequence of cerebrospinal fluid loss, leading to reduced intracranial pressure. Its classical symptoms include a frontal‐occipital headache which is worse on standing, neck stiffness, nausea, hearing loss and photophobia. In this report, we describe an atypical presentation of post‐dural puncture headache in a 72‐year‐old woman following an endovascular repair of an aortic aneurysm, before which a lumbar spinal drain was placed to reduce the risk of spinal cord ischemia. Following drain removal, the patient developed hypoactive delirium, challenges with both depth perception and fine motor skills and a mild headache. An epidural blood patch was performed, which resulted in the complete resolution of her symptoms. This case highlights an atypical presentation of post‐dural puncture headache in an older patient, in whom the major symptoms were cognitive. Cerebrospinal fluid leakage should be considered as a cause of postoperative delirium in patients who have undergone neuraxial anaesthesia.

Autologous blood patch pleurodesis for prolonged postoperative air leaks

Background

A prolonged air leak (PAL) is the most frequent complication after pulmonary resection. This study aimed to assess the safety and efficacy of autologous blood patch pleurodesis (ABPP) to treat PAL.

Methods

A prospectively maintained database identified patients with a PAL after pulmonary resection for lung cancer between 2015–2019. In this observational cohort study, clinical data were collected to retrospectively compare patients undergoing ABPP to no ABPP in a propensity-matched analysis. Kaplan Meier estimates and Cox models accounting for inverse probability weighting (IPTW) were used to assess the association of ABPP with each outcome.

Results

Of the 740 patients undergoing lung resection, 110 (15%) were identified as having a PAL at postoperative day (POD) 5. There was no difference between baseline characteristics among those undergoing ABPP (n=34) versus no ABPP (n=76). Propensity-weighted analysis did not reveal a significant association of ABPP treatment with in-hospital complication (P=0.18), hospital length of stay (LOS) (P=0.13), or post-discharge complication (P=0.13). However, ABPP treatment was associated with a lower risk of hospital readmission [P=0.02, hazard ratio (HR) 0.16] and reoperation for air leak or empyema (P=0.05, HR 0.11). Although not statistically significant, the mean chest tube (CT) removal of 11 days for the ABPP group was less than the no ABPP group (16 days) (P=0.14, HR 1.5–2). Those treated with ABPP were less likely to be discharged with a CT (ABPP 7/34, 21% vs. no ABPP 40/76, 53%). There was no statistical difference in empyema development between groups (ABPP 0/34, 0% vs. no ABPP 4/76, 5%, P=0.39, HR 0.24).

Conclusions

ABPP administration is safe compared to traditional PAL management. In a retrospective propensity-matched analysis, postoperative patients treated with ABPP required less readmission and reoperation for PAL. Larger powered randomized trials may demonstrate the magnitude of benefit from treatment with ABPP.

Epidural Contrast Volume on Post-Myelogram Lumbar CT Predicts the Rate of Subsequent Blood Patch Treatment

BACKGROUND AND PURPOSE

Headaches due to cerebrospinal fluid (CSF) leakage are a well-known complication of dural puncture. The purpose of this study was to determine whether the presence and volume of epidural contrast on postmyelogram CTs of the lumbar spine were associated with post-dural puncture headaches (PDPHs) requiring epidural blood patch (EBP) treatment.

METHODS

A retrospective case control study of all fluoroscopically guided lumbar myelograms performed over a 5-year period by a single radiology practitioner assistant was performed. Ten patients who underwent EBP treatment after their myelograms were identified. Forty-six patients with similar demographics who did not receive blood patches were then selected. CT-lumbar myelogram images of patients and controls were reviewed. The volume of epidural contrast was then quantified as "severe" or "mild." Severe epidural contrast was defined as contrast detected in the ventral epidural space, the extra-foraminal space, or extending greater than or equal to the length of two vertebral bodies from the level of dural puncture.

RESULTS

Some amount of epidural contrast was seen in all patients. However, a severe volume of epidural contrast was associated with increased risk for PDPH requiring an EBP (odds ratio = 37.00; 95% CI = 4.1-330.8, p = 0.0012).

CONCLUSION

Severe epidural contrast on postmyelogram CTs of the lumbar spine was associated with an increased risk of PDPH requiring EBP treatment. When present, this finding can alert the proceduralist that the patient may require closer observation and follow up with earlier intervention.

Allogenic blood patch pleurodesis for continuous pneumothorax in three cats

Case series summary

Following diaphragmatic herniorrhaphy, three cats developed a continuous pneumothorax. All three cats required continuous suction to evacuate air from the thoracic cavity. Despite continuous suction, the pneumothorax persisted for all cats and blood patch pleurodesis (BPP) was performed using blood donor cats. All three cats had resolution of their pneumothorax within 24 h of BPP.

Relevance and novel information

This is the first report of BPP used in feline patients. More recently autologous BPP has been reported for use in dogs and humans, with a reportedly high success rate. BPP may allow timely resolution of continuous pneumothorax in cats and provide an alternative treatment option to prolonged medical management or surgical intervention. Allogenic blood from a donor cat may be necessitated in feline BPP when cardiovascular instability is appreciated in these small patients.

Perilymphatic Fistula: A Review of Classification, Etiology, Diagnosis, and Treatment

A perilymphatic fistula (PLF) is an abnormal communication between the perilymph-filled inner ear and the middle ear cavity, mastoid, or intracranial cavity. A PLF most commonly forms when the integrity of the oval or round window is compromised, and it may be trauma-induced or may occur with no known cause (idiopathic). Controversy regarding the diagnosis of idiopathic PLF has persisted for decades, and the presenting symptoms may be vague. However, potential exists for this condition to be one of the few etiologies of dizziness, tinnitus, and hearing loss that can be treated surgically. The aim of this review is to provide an update on classification, diagnosis, and treatment of PLF. Particular attention will be paid to idiopathic PLF and conditions that may have a similar presentation, with subsequent information on how best to distinguish them. Novel diagnostic criteria for PLF and management strategy for PLF and PLF-like symptoms is presented.

Use of a Triple Prophylactic Strategy to Prevent Post-dural Puncture Headache: An Observational Study

Objective

Post-dural puncture headache (PDPH) after an accidental dural puncture is a very common complication of epidural analgesia/anesthesia. We observed the ability of a triple prophylactic method (epidural saline, morphine, and intravenous (IV) cosyntropin) to prevent PDPH and the need for a blood patch. 

Methods

We retrospectively evaluated the effect of the combination of epidural saline, IV cosyntropin, and epidural morphine in parturients who had an accidental dural puncture with regard to the PDPH rate and the need for an epidural blood patch. We report a case series of patients with accidental dural puncture who underwent triple prophylaxis and other methods.

Results

Thirty-one patients were included in the study. Fourteen cases received triple prophylaxis (45%). Three patients in this group developed PDPH (21%), with two of them requiring a blood patch (14%). Nine patients underwent preventive measures other than triple prophylaxis with a PDPH rate of 55% and one needing a blood patch (11%). Conservative management was used in eight patients with PDPH and blood patch rates of 100% and 62%, respectively.

Conclusion

The triple prophylactic regimen of epidural saline, IV cosyntropin, and epidural morphine used after accidental dural puncture exhibits great potential to reduce the incidence of PDPH and the need for blood patch in obstetric patients.

Autologous Blood Patch for Persistent Ascites Leak from Non-Closing Paracentesis Tracts

Ascites, the fluid accumulation in the peritoneal cavity, is most commonly seen in patients with end-stage liver disease (ESLD). Evaluating ascites or providing symptomatic relief for patients is accomplished by performing a paracentesis. Ascites leak from a paracentesis site can be a complication of the procedure and is associated with increased morbidity. Currently, the best options for these patients include medical management or surgical abdominal wall layer closure. Utilizing a blood patch provides an alternative approach to managing such patients. A two-center prospective case series was performed evaluating the efficacy of the blood patch in patients with significant persistent ascites leak following a paracentesis. About 30 mL of the patients' peripheral blood was used for the blood patch. Subjects were recruited over a period of one year and followed for 30 days after the procedure. A total of six patients were recruited for this study. Subjects underwent placement of autologous blood patch at the site of the ascites leak and 100% had resolution of the leak within 24 hours. None of the subjects developed any complications of the procedure. This study shows that an autologous blood patch is an effective, low-risk treatment method for ascites leaks following a paracentesis. It is a simple bedside procedure that can reduce morbidity in patients with end-stage liver disease.

Subdural Hematoma as a Consequence of Labor Epidural Analgesia

Subdural hematoma (SDH) following labor epidural analgesia is a rare neurological complication. SDH is a late complication of this procedure; it is caused by a leak of cerebrospinal fluid that may damage the vascular structures of the brain. Persistent headache in the days after labor epidural analgesia is a nonspecific clinical symptom caused by hematoma. Preexisting vascular malformations can be a concomitant cause of headache. Clinical cases have been reported even after epidural anesthesia. The differential diagnosis includes unspecified headache, sinusitis headache, drug-induced headache, cortical vein thrombosis, fistula of the dura mater, and bacterial, viral, and aseptic meningitis.

Use of autologous blood patch for prolonged air leak in spontaneous pneumothoraces in the adolescent population

Instillation of an autologous blood patch for prolonged air leak (PAL) in chest tube system has been studied and determined to be a safe and effective treatment plan for adults. The current recommended treatment guidelines for a PAL in adolescent secondary to a spontaneous pneumothorax are surgical intervention. This paper serves as documentation of two case reports with successful treatment of PALs with autologous blood patch in two adolescent patients.

Unusual presentation of postdural puncture headache requiring repeat epidural blood patch in a 4-year-old child

We present the case of a 4-year-old child who required two epidural blood patches (EBPs) to treat a delayed onset postdural puncture headache (PDPH) caused by lumbar cerebrospinal fluid drain. The first EBP was unsuccessful with 0.41 ml·kg(-1) of blood injected. A second EBP with 0.76 ml·kg(-1) of blood was performed 2 days later with the complete resolution of symptoms. The volume of blood necessary for effective treatment for symptomatic cerebrospinal fluid leaks in children remains controversial, and a repeat EBP may be required for resolution of symptoms.

Epidural Blood Patches in a Patient With Multi-level Cerebrospinal Fluid Leakage That Was Induced by Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is considered to be a very rare disorder. It is characterized by an orthostatic headache that is aggravated with the patient in the upright position and it is relieved by the patient assuming the supine position. SIH is caused by a spontaneous spinal cerebrospinal fluid leakage without the patient having undergone trauma, surgery or dural puncture or having any other significant medical history. An autologous epidural blood patch (EBP) is effective in relieving SIH. We report here on a case of SIH with cerebrospinal fluid leakage at the upper cervical vertebral level and the middle thoracic vertebral level. The points of leakage were identified by radionuclide cisternography, and this patient was successfully managed by injecting an EBP at each level of leakage.