When epidural blood patching is unsuccessful or if symptoms recur, spinal imaging findings help to guide further treatment. Dec 20, 2019 a csf leak that does not respond to conservative treatment may require more invasive approaches, such as those below. Complexities of low csf volume headache mayo clinic. Leakage detection on ct myelography for targeted epidural. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease. Dec 11, 2019 my spontaneous leak first started on 32720 and i was diagnosed with spontaneous csf leak on 32920 after mri showed fluid pooled. Spontaneous c12 csf leak treated with high cervical epidural. Two weeks later i went back for a blood patch which relieved most of the pain resulting from an apparent csf leak. Cerebrospinal fluid csf leak management and treatment.
Sih with a csf leak at the upper cervical spine may be least amenable to conventional epidural blood patch delivered from the lumbar spine. These headaches are typically postural in character, can be severe, and may be associated with nausea, vomiting, neck stiffness, and dizziness. Here, we report a case of a patient in whom scfl failed to resolve after three applications of interlaminar ebps before finally being successfully treated with transforaminal ebp. Spontaneous intracranial hypotension treated with a targeted. Spontaneous intracranial hypotension sih is typically the result of spontaneous cerebral spinal fluid csf leak at the spine level. When the cause cannot be identified, the set of symptoms is referred to as spontaneous cerebrospinal fluid leak syndrome scsfls. The efficacy of epidural blood patch in spontaneous csf. Jul 26, 2019 as our understanding of this syndrome is still evolving, the terms low csf pressure headache, spontaneous intracranial hypotension, spontaneous csf leak, csf hypovolemia, and csf volume depletion tend to be used interchangeably. Mayo clinic patients with a diagnosis of spontaneous intracranial hypotension csf leak from 111996 to 432015 who received epidural blood patch or fibrin glue injection. A spontaneous csf leak and the clinical syndrome that it causes may be confused with a postdural puncture headache. Thoracic blood patch, partial success spinal csf leak.
Spontaneous intracranial hypotension sih results from leaks developing in the dura mater. Headaches secondary to leakage of cerebrospinal fluid csf, either related to recent dural puncture or spontaneous leakage, have been well described. A directed epidural blood patch, placed in close proximity to the level of suspected csf leak, is effective in most patients. For the past 20 days, i have been suffering with a postural headache of unknown origin. Blood patch for spontaneous intracranial hypotension caused.
Effectiveness of epidural blood patch in the management of. My mom just had a blood patch done for spontaneous intercranial hypotension. Sih is caused by an atraumatic cerebrospinal fluid csf leak usually secondary to structural dural weakness. Postdural puncture headache versus spontaneous csf leaks.
After conservative treatments have been tried, an epidural blood patch is the most common treatment for spinal csf leaks. An epidural blood patch is a surgical procedure that provides immediate relief to the headache caused by leaking spinal fluid. Surgical repair of spinal csf leaks have good success rates in the hands of experienced neurosurgeons. This is most often done with fluoroscopic guidance and intravenous sedation by an anesthesiologist or a radiologist. Key factors determine success of epidural patch for csf leaks. The use of fibrin sealant requires the identification of the exact site of the csf leak as, in contrast to autologous blood, it. The blood clot that forms creates a seal to stop the leak. If several attempts of epidural blood patches do not work, other grafting.
Csf leaks have been traditionally classified as traumatic or nontraumatic 1. This patient received two lumbar epidural blood patches without lasting relief. Spontaneous intracranial hypotension sih is an important cause of new daily persistent headache. Successful treatment of spontaneous cerebrospinal fluid. Of eight patients who received three or more ebp mean 4, four patients 50% responded well. Methods ninetyfour patients with sih underwent ebps. Fluoroscopicallyguided epidural blood patch for spontaneous. If symptoms recur, a repeat procedure may be performed. Postepidural blood patch precautions guidance csf leak. Spontaneous intracranial hypotension sih is rare, often misdiagnosed, as a cause of postural headaches. Given the radiographic evidence of prominent csf leak with extradural fluid collection at c12 level, the patient was then treated with a cervical epidural blood patch, which provided headache pain relief lasting 6 months. Low csf pressure headache is almost always due to csf leakage, which can be iatrogenic, traumatic, or spontaneous in origin. Injectate volume was variable and guided by the onset of back pain, radiculopathy or symptoms referable to the ebp.
A recent report suggested epidural fibrin glue application should epidural blood patching fail. After blood patching, while restrictions are individualized, it is typical for physicians to recommend avoidance of bending, lifting and twisting, as well as straining valsalva for about 46 weeks. Imagingguided precise placement of the blood patch is safe and. However, if a csf leak is not fixed, there are also risks associated with that including subdural hematoma, blindness and brain herniation which have been reported in medical literature. Lumbar epidural blood patches ebps can be effective in relieving headaches, however. During leak week uk 2018, we published brand new guidance on sensible precautions to take after an epidural blood patch. Transforaminal epidural blood patch for intractable. Epidural patching medical clinical policy bulletins aetna. Delivery of autologous blood patch via an epidural catheter inserted from the lower cervical spine can be a safe and effective method for such patients. The content on this site is presented in a summary fashion, and is intended to be used for educational and entertainment purposes only. Blind epidural blood patch for spontaneous intracranial. Whilst this guidance has been produced in consultation with uk neurologists, as always, we would strongly encourage you to seek and follow advice from your own doctor.
Epidural blood patch ebp the patients own blood is injected into the epidural space, the space just outside the dura within the spinal canal, forming a patch over the dura. Epidural blood patches are a common type of medical intervention for cases where a spinal csf leak hasnt healed on its own accord. When to suspect a csf leak in patients with headache. The demonstration of a spinal csf leak ie, the presence of extrathecal csf is sufficient to diagnose spontaneous intracranial hypotension, regardless of associated symptoms, imaging findings, or results of lumbar puncture and epidural blood patching. It now appears that the core pathogenic factor in sih is decreased csf volume rather than decreased csf opening pressure. A blood patch is a medical procedure that is used to close cerebral spinal fluid csf leaks.
Background and objective epidural blood patch ebp is a safe and effective treatment for spontaneous intracranial hypotension sih, but clinical and procedural variables that predict ebp efficacy remain nebulous. The technique of epidural blood patch has been described elsewhere. High thoraciccervical epidural blood patch for spontaneous. Mar 08, 2018 during leak week uk 2018, we published brand new guidance on sensible precautions to take after an epidural blood patch. Apr 17, 2020 my spontaneous leak first started on 32720 and i was diagnosed with spontaneous csf leak on 32920 after mri showed fluid pooled in epidural space in thoracic level from t2 through t10. Deepak demonstrate the process of administering an epidural blood patch for spontaneous csf leak from the lumbar area. My spontaneous leak first started on 32720 and i was diagnosed with spontaneous csf leak on 32920 after mri showed fluid pooled. In this procedure, your own blood is injected into the spinal canal.
In consideration of the above points, the placement of an ebp near the leak might be more effective. Researchers are gaining more insight into the factors that best predict the efficacy of an epidural blood patch in patients with spontaneous cerebrospinal fluid hypovolemia. Cervical epidural blood patch for low csf pressure. Its concerning that you have multiple csf leaks that appear to be. In the following 20 months i actively sought medical treatment for chronic head pain and migraine. The classic manifestation of sih is an orthostatic headache, but other neurological symptoms may be present. Oct 11, 2005 low csf pressure headache is divided by the international headache society into three categories.
A favorable response to an epidural blood patch supports the diagnosis of a leak but often lacks durability. If the first lumbar blood patch is ineffective, a second blood patch is applied in the thoracic region. Diagnostic criteria for spontaneous spinal csf leaks and. The efficacy of epidural blood patch in spontaneous csf leaks. Spontaneous intracranial hypotension is an increasingly recognized cause of new daily persistent headaches, particularly among young and middleaged people, but an initial misdiagnosis remains common. There is up to a 90% response to a single epidural blood patch. Blood patch for spontaneous intracranial hypotension. The vertebral space where the ebp was performed is depicted in figure 2. Almost all cases of sih are a result of spontaneous spinal csf leakage from spinal meningeal diverticula or simple dural tears. Spontaneous intracranial hypotension sih, also known as spontaneous cerebrospinal fluid csf hypovolemia or craniospinal hypovolemia, typically results from a spinal level csf leak. Many patients worry about the procedure, wondering what the whole experience will be like, what to expect and whether or not its painful.
A csf leak can occur when there is a tear or puncture in the dura the membrane that surrounds the brain and spinal cord that causes the watery protective fluid csf that circulates around these neurological structures to. Thoracic epidural blood patches in the treatment of. Spontaneous intracranial hypotension treated with a. A generous csf leak was identified at c2 on ct myelography. Epidural blood patch an overview sciencedirect topics. Nov 27, 2001 of 25 consecutive patients with spontaneous csf leaks treated with epidural blood patch ebp, nine patients 36% responded well to the first ebp. Imagingguided precise placement of the blood patch is safe and recommended. Successful treatment was performed with ctguided blood patch at the leakage site after the patient had failed 2 lumbar blood patches. A recent report suggested epidural fibrin glue application should epidural blood patching fail 23. This technique effectively seals the csf leak in about onethird of sih patients in whom the epidural blood patch was ineffective schievink et al. The purpose of this study was to describe significant ct myelography findings for determination of the leak site and outcome of targeted epidural blood patch ebp in patients with spontaneous csf leaks. Clinically, it is characterized by orthostatic headache and may respond well to epidural blood patch.
Once identified, the leak can often be repaired by an epidural blood patch, an injection of the patients own blood at the site of the leak, a fibrin glue injection, or surgery. Low csf pressure headache is divided by the international headache society into three categories. A csf leak can occur when there is a tear or puncture in the dura the membrane that surrounds the brain and spinal cord that causes the watery protective fluid csf that circulates around these neurological structures to leak out. Of 25 consecutive patients with spontaneous csf leaks treated with epidural blood patch ebp, nine patients 36% responded well to the first ebp. Previously, ebps were performed using anatomical landmarks. Successful treatment of spontaneous cerebrospinal fluid leak. My spontaneous leak first started on 32720 and i was diagnosed with spontaneous csf leak on 32920 after mri showed fluid pooled in epidural space in thoracic level from t2 through t10.
Cervical epidural blood patch for low csf pressure headaches. Csf leak 2 weeks post epidural blood patch duration. It is thought to be due to spontaneous spinal cerebrospinal fluid csf leaks, which probably have a multifactorial etiology. Our initial assessment concluded that the diagnosis of sih was not in question. Patients with post traumatic and postsurgical cases. Aug 17, 2018 a blood patch is not advised in the case of a fever. Spontaneous intracranial hypotension results from cerebrospinal fluid leakage.
Spontaneous intracranial hypotension and spontaneous csf leaks due to dura mater dm weakening affect women twice as often as men, and the onset of symptoms occurs typically in the fourth or. Epidural blood patch can cause acute neurologic deterioration. A csf leak that does not respond to conservative treatment may require more invasive approaches, such as those below. The major symptom is orthostatic headache which gradually disappears after lying down.
Epidural blood patch was performed after a median delay of 4 days range, 153 days after dural puncture. Background we report a retrospective analysis of a twolevel, variablevolume epidural blood patch ebp technique for the treatment of spontaneous intracranial hypotension sih. Currently, the treatment of choice for spontaneous intracranial hypotension is the epidural blood patch, which has a. The use of fibrin sealant requires the identification of the exact site of the csf leak as, in contrast to autologous blood, it is injected directly into the vicinity of the leak. After the injection of your blood, the bodys own healing system should take over and finish repairing the spinal fluid leak. Accessing the spinal epidural space can be done under fluoroscopy or ct, and is essentially identical to one described in the article on lumbar interlaminar epidural injection. Spontaneous intracranial hypotension sih was originally described by schaltenbrand in 1938 and is a syndrome featuring low cerebrospinal fluid csf pressure resulting from csf leakage without any history of dural puncture, surgery, or penetrating trauma most sih patients present with a mild postural headache, which spontaneously resolves within a few days.
The exact site of csf leak could not be identified. With a postdural puncture headache, a patient usually has a single leak site in the dorsal dura. It covers a range of key considerations for things to avoid or consider if youve recently had an epidural blood patch to resolve a spinal csf leak. Discomfort occurred in 391 cases 78% after administration of a blood volume of 19 5 ml. Epidural blood patch was performed at the t1 to t2 level, the presumed location of the leak due to presence of a bone spur on ct and the large corresponding csf collection. Mayo clinic patients with a diagnosis of spontaneous intracranial hypotensioncsf leak from 111996 to 432015 who received epidural blood patch or fibrin glue injection. The etiology of spontaneous csf leakage remains unclear, and the leakage site can be anywhere along the spinal column but is usually at the thoracic or low cervical level. Nontraumatic csf leak may be spontaneous in the absence of obvious cause, such as skull base abnormalities or bone erosion related to tumors or hydrocephalus 2. A lumbar epidural autologous blood patch is usually placed in sih patients because the lumbar ebp is effective in 90% of cases. Spontaneous intracranial hypotension in a 37yearold man with intractable headaches was diagnosed on mr imaging. Although well described from other parts of the world, there exists a remarkable paucity of reports of sih from india. Epidural blood patch what is an epidural blood patch. This quickly led to resolution of the headache and cranial nerve palsies, and later to the complete resolution of his sdh.
The patient was subsequently referred for an anaesthetic opinion with a view to treatment using an epidural blood patch ebp. A twolevel largevolume epidural blood patch protocol for. As our understanding of this syndrome is still evolving, the terms low csf pressure headache, spontaneous intracranial hypotension, spontaneous csf leak, csf hypovolemia, and csf volume depletion tend to be used interchangeably. Approximately 1520 mls of blood is taken from a vein in the patients arm and subsequently injected into the epidural space in. Successful treatment of spontaneous intracranial hypotension.
Blood patch experiences epidural blood patches are a common type of medical intervention for cases where a spinal csf leak hasnt healed on its own accord. An epidural blood patch is thought to be the most effective. Procedural predictors of epidural blood patch efficacy in. A small number of patients usually less then 10% may need to have a second blood patch.
Epidural patching with fibrin sealant may be directed at the leak location or a surgical repair may be the best option. In one 2016 study, researchers compared the success rates of epidural blood patches in 3 people with csf. Of 15 patients who received a second ebp, five became asymptomatic 33%. Epidural blood patch ebp is a recognized treatment for spontaneous cerebrospinal fluid leak scfl and is typically administered by the interlaminar approach. Epidural blood patches have high success rates but may not cure all types of csf leaks.
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