Lack of Increase in Intracranial Pressure after Epidural Blood patch in Spinal Cerebrospinal Fluid Leak

Background and Importance: Epidural blood patch (EBP) is one therapeutic measure for patients suffering from spontaneous intracranial hypotension (SIH) or postlumbar puncture headaches. It has been proposed that an EBP may directly seal a spinal cerebrospinal fluid (CSF) fistula or result in an increase in intracranial pressure (ICP) by a shift of CSF from the spinal to the intracranial compartment. To the best of our knowledge this is the first case of a patient with SIH and neurological deterioration in whom ICP was measured before, during, and after spinal EBP.

Clinical Presentation: This 52-year-old previously healthy man presented with holocephalic headaches. Magnetic resonance imaging showed a left hemispheric subdural fluid collection causing a significant mass effect. Myelography revealed a CSF leak with epidural contrast at the left side of the L-2 level. To seal the CSF leak, we performed an EBP procedure targeted at left L-2 level and recorded ICP. After applying the EBP (15 cc) the patient improved rapidly; ICP, however, remained unchanged before, during, and after the procedure. One day posttreatment, he had a Glasgow Coma Scale score increase from 12 to 15 and no headache or neurological deficits.

Conclusion: A shift of CSF from the spinal to the cranial compartment with a subsequent rise in ICP might not be a beneficial therapeutic mechanism of spinal EBP.