Download PDF
J Neurol Surg B Skull Base 2018; 79(03): 217-223
DOI: 10.1055/s-0037-1606312
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Targeted Epidural Blood Patch Treatment for Refractory Spontaneous Intracranial Hypotension in China

Fei-Fang He
1   Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
,
Li Li
2   Department of Family Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
,
Min-Jun Liu
1   Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
,
Tai-Di Zhong
1   Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
,
Qiao-Wei Zhang
3   Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
,
Xiang-Ming Fang
4   Department of Anesthesiology, The first affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China
› Author Affiliations
Further Information

Publication History

13 October 2016

26 July 2017

Publication Date:
11 September 2017 (online)

    Permissions and Reprints

Abstract

Objective An epidural blood patch (EBP) is the mainstay of treatment for refractory spontaneous intracranial hypotension (SIH). We evaluated the treatment efficacy of targeted EBP in refractory SIH.

Methods All patients underwent brain magnetic resonance imaging (MRI) with contrast and heavily T2-weighted spine MRI. Whole spine computed tomography (CT) myelography with non-ionic contrast was performed in 46 patients, and whole spine MR myelography with intrathecal gadolinium was performed in 119 patients. Targeted EBPs were placed in the prone position one or two vertebral levels below the cerebrospinal fluid (CSF) leaks. Repeat EBPs were offered at 1-week intervals to patients with persistent symptoms, continued CSF leakage, or with multiple leakage sites.

Results Brain MRIs showed pachymeningeal enhancement in 127 patients and subdural hematomas in 32 patients. One hundred fifty-two patients had CSF leakages on heavily T2-weighted spine MRIs. CSF leaks were also detected on CT and MR myelography in 43 and 111 patients, respectively. Good recovery was achieved in all patients after targeted EBP. No serious complications occurred in patients treated with targeted EBP during the 1 to 7 years of follow-up.

Conclusions Targeted and repeat EBPs are rational choices for treatment of refractory SIH caused by CSF leakage.

Keywords

SIH - CSF leakage - targeted EBP - treatment
 

  • References

  • 1 Schaltenbrand G. Neuere anschauungen zur pathophysiologie der liquorzirkulation. Zentralbl Neurochir 1938; 3: 290-300
    PubMedGoogle Scholar
  • 2 Schievink WI. Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia 2008; 28 (12) 1345-1356
    CrossrefPubMedGoogle Scholar
  • 3 Mokri B. Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia--evolution of a concept. Mayo Clin Proc 1999; 74 (11) 1113-1123
    CrossrefPubMedGoogle Scholar
  • 4 Mokri B. Low cerebrospinal fluid pressure syndromes. Neurol Clin 2004; 22 (01) 55-74 , vi
    CrossrefPubMedGoogle Scholar
  • 5 Rahman M, Bidari SS, Quisling RG, Friedman WA. Spontaneous intracranial hypotension: dilemmas in diagnosis. Neurosurgery 2011; 69 (01) 4-14 , discussion 14
    CrossrefPubMedGoogle Scholar
  • 6 Kim SY, Hong JH. Epidural blood patches in a patient with multi-level cerebrospinal fluid leakage that was induced by spontaneous intracranial hypotension. Korean J Pain 2010; 23 (01) 46-50
    CrossrefPubMedGoogle Scholar
  • 7 Benzon HT, Nemickas R, Molloy RE, Ahmad S, Melen O, Cohen B. Lumbar and thoracic epidural blood injections to treat spontaneous intracranial hypotension. Anesthesiology 1996; 85 (04) 920-922
    CrossrefPubMedGoogle Scholar
  • 8 Peng PW, Farb R. Spontaneous C1-2 CSF leak treated with high cervical epidural blood patch. Can J Neurol Sci 2008; 35 (01) 102-105
    CrossrefPubMedGoogle Scholar
  • 9 Rai A, Rosen C, Carpenter J, Miele V. Epidural blood patch at C2: diagnosis and treatment of spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2005; 26 (10) 2663-2666
    PubMedGoogle Scholar
  • 10 Hannerz J, Dahlgren G, Irestedt L, Meyerson B, Ericson K. Treatment of idiopathic intracranial hypotension: cervicothoracic and lumbar blood patch and peroral steroid treatment. Headache 2006; 46 (03) 508-511
    CrossrefPubMedGoogle Scholar
  • 11 Sencakova D, Mokri B, McClelland RL. The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology 2001; 57 (10) 1921-1923
    CrossrefPubMedGoogle Scholar
  • 12 Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. Cephalalgia 2004; 24 (Suppl. 01) 79-80
    PubMedGoogle Scholar
  • 13 Schievink WI. Misdiagnosis of spontaneous intracranial hypotension. Arch Neurol 2003; 60 (12) 1713-1718
    CrossrefPubMedGoogle Scholar
  • 14 Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 2006; 295 (19) 2286-2296
    CrossrefPubMedGoogle Scholar
  • 15 Schievink WI, Schwartz MS, Maya MM, Moser FG, Rozen TD. Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks. J Neurosurg 2012; 116 (04) 749-754
    CrossrefPubMedGoogle Scholar
  • 16 Shima K, Ishihara S, Tomura S. Pathophysiology and diagnosis of spontaneous intracranial hypotension. Acta Neurochir Suppl (Wien) 2008; 102: 153-156
    PubMedGoogle Scholar
  • 17 Schievink WI, Maya MM, Moser F, Tourje J, Torbati S. Frequency of spontaneous intracranial hypotension in the emergency department. J Headache Pain 2007; 8 (06) 325-328
    CrossrefPubMedGoogle Scholar
  • 18 Mokri B. Spontaneous intracranial hypotension. Continuum (Minneap Minn) 2015; 21 (4 headache): 1086-1108
    PubMedGoogle Scholar
  • 19 Mokri B. Headaches caused by decreased intracranial pressure: diagnosis and management. Curr Opin Neurol 2003; 16 (03) 319-326
    CrossrefPubMedGoogle Scholar
  • 20 Paldino M, Mogilner AY, Tenner MS. Intracranial hypotension syndrome: a comprehensive review. Neurosurg Focus 2003; 15 (06) ECP2
    PubMedGoogle Scholar
  • 21 Mokri B. Spontaneous intracranial hypotension. Curr Pain Headache Rep 2001; 5 (03) 284-291
    CrossrefPubMedGoogle Scholar
  • 22 Berroir S, Loisel B, Ducros A. , et al. Early epidural blood patch in spontaneous intracranial hypotension. Neurology 2004; 63 (10) 1950-1951
    CrossrefPubMedGoogle Scholar
  • 23 Schievink WI, Maya MM, Moser FM. Treatment of spontaneous intracranial hypotension with percutaneous placement of a fibrin sealant. Report of four cases. J Neurosurg 2004; 100 (06) 1098-1100
    CrossrefPubMedGoogle Scholar
  • 24 Franzini A, Messina G, Nazzi V. , et al. Spontaneous intracranial hypotension syndrome: a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients. J Neurosurg 2010; 112 (02) 300-306
    CrossrefPubMedGoogle Scholar
  • 25 Ferrante E, Arpino I, Citterio A, Wetzl R, Savino A. Epidural blood patch in Trendelenburg position pre-medicated with acetazolamide to treat spontaneous intracranial hypotension. Eur J Neurol 2010; 17 (05) 715-719
    CrossrefPubMedGoogle Scholar
  • 26 Madsen SA, Fomsgaard JS, Jensen R. ; Soren Aalb. Epidural blood patch for refractory low CSF pressure headache: a pilot study. J Headache Pain 2011; 12 (04) 453-457
    CrossrefPubMedGoogle Scholar
  • 27 Mokri B, Maher CO, Sencakova D. Spontaneous CSF leaks: underlying disorder of connective tissue. Neurology 2002; 58 (05) 814-816
    CrossrefPubMedGoogle Scholar
  • 28 Schievink WI, Maya MM, Louy C, Moser FG, Tourje J. Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol 2008; 29 (05) 853-856
    CrossrefPubMedGoogle Scholar
  • 29 Cho KI, Moon HS, Jeon HJ, Park K, Kong DS. Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch. Neurology 2011; 76 (13) 1139-1144
    CrossrefPubMedGoogle Scholar
  • 30 Wang YF, Lirng JF, Fuh JL, Hseu SS, Wang SJ. Heavily T2-weighted MR myelography vs CT myelography in spontaneous intracranial hypotension. Neurology 2009; 73 (22) 1892-1898
    CrossrefPubMedGoogle Scholar
  • 31 Watanabe A, Horikoshi T, Uchida M, Koizumi H, Yagishita T, Kinouchi H. Diagnostic value of spinal MR imaging in spontaneous intracranial hypotension syndrome. AJNR Am J Neuroradiol 2009; 30 (01) 147-151
    CrossrefPubMedGoogle Scholar
  • 32 Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache 2013; 53 (07) 1034-1053
    CrossrefPubMedGoogle Scholar
  • 33 Mokri B. Radioisotope cisternography in spontaneous CSF leaks: interpretations and misinterpretations. Headache 2014; 54 (08) 1358-1368
    CrossrefPubMedGoogle Scholar
  • 34 Mokri B. Spontaneous CSF leaks: low CSF volume syndromes. Neurol Clin 2014; 32 (02) 397-422
    CrossrefPubMedGoogle Scholar
  • 35 Schievink WI, Maya MM, Moser FG, Tourje J. Spectrum of subdural fluid collections in spontaneous intracranial hypotension. J Neurosurg 2005; 103 (04) 608-613
    CrossrefPubMedGoogle Scholar
  • 36 Schievink WI, Maya MM, Pikul BK, Louy C. Spontaneous spinal cerebrospinal fluid leaks as the cause of subdural hematomas in elderly patients on anticoagulation. J Neurosurg 2010; 112 (02) 295-299
    CrossrefPubMedGoogle Scholar
  • 37 Allegri M, Lombardi F, Custodi VM. , et al. Spontaneous cervical (C1-C2) cerebrospinal fluid leakage repaired with computed tomography-guided cervical epidural blood patch. J Pain Symptom Manage 2010; 40 (03) e9-e12
    PubMedGoogle Scholar
  • 38 Kranz PG, Amrhein TJ, Gray L. Rebound intracranial hypertension: a complication of epidural blood patching for intracranial hypotension. AJNR Am J Neuroradiol 2014; 35 (06) 1237-1240
    CrossrefPubMedGoogle Scholar
  • 39 Gladstone JP, Nelson K, Patel N, Dodick DW. Spontaneous CSF leak treated with percutaneous CT-guided fibrin glue. Neurology 2005; 64 (10) 1818-1819
    CrossrefPubMedGoogle Scholar