Epidural blood patch ebp is a standard treatment of spontaneous intracranial hypotension sih. Spontaneous intracranial hypotension treated with a. Epidural blood patch for spontaneous intracranial hypotension with. A nontargeted epidural blood patch is often used in cases of spontaneous intracranial hypotension, on the assumption that the leak is from the spine, with variable success 9. Cervical dural csf leak on mri and ct treated by blood patch. A complete cure was obtained in 77% of patients after one 57% or two 20% ebps. Intracranial hypotension with severe neurological symptoms resolved by epidural blood patch volume 31 issue 4 philip w. Because the symptoms of rebound intracranial hypertension may bear some similarity to those of intracranial hypotension and literature reports of. The classic manifestation of sih is an orthostatic headache, but other neurological symptoms may be present. Thoracic epidural blood patch for spontaneous intracranial hypotension. Spontaneous intracranial hypotension with typical orthostatic headache can be diagnosed without lumbar puncture and can be cured by early ebp in a majority of patients. All correspondence should be addressed to dr david bogod, editor of anaesthesia, ist floor, maternity unit, nottingham city hospital, hucknall. All correspondence should be addressed to dr david bogod, editor of anaesthesia, ist floor, maternity unit, nottingham city hospital, hucknall road, nottingham ng5 1pb, uk. The headache associated with intracranial hypotension typically improves while the patient is recumbent and worsens upon sitting or standing.
Efficacy of epidural blood patch with fibrin glue additive in refractory headache due to intracranial hypotension. Blind epidural blood patch for spontaneous intracranial. Total spinal epidural blood patch application through a. Spontaneous intracranial hypotension sih is an unusual clinical entity in which patients often present with a spectrum of clinical signs and symptoms. We present a 37yearold man who developed a 4 week duration postural headache without sustaining significant trauma. Jul 18, 2011 this case report describes the successful treatment of chronic headache from intracranial hypotension with bilateral transforaminal tf lumbar epidural blood patches ebps. An epidural blood patch is thought to be the most effective treatment, but a blind infusion may be ineffective.
Early epidural blood patch in spontaneous intracranial hypotension neurology. Multiple imaging modalities may be used in defining this disease, and following the. Spontaneous intracranial hypotension with typical orthostatic headache can be diagnosed. Blood patch therapy for spontaneous intracranial hypotension. Intracranial hypotension can be defined as a medical condition, in which the pressure within the brain cavity is negative. A twolevel largevolume epidural blood patch protocol for. Spontaneous intracranial hypotension sih is rare, often misdiagnosed, as a cause of postural headaches. Iatrogenic intracranial hypotension can occur due to dural pucture, trauma and spine surgery.
Spontaneous intracranial hypotension treatment siht. The brain and spinal cord are covered by a tough, watertight membrane called the dura. Transforaminal blood patch for the treatment of chronic. 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. Her comments on the draft manuscript have been incorporated in the revised paper. How patients were involved in the creation of this article.
Spontaneous intracranial hypotension the spine hospital. Ctguided epidural blood patching of directly observed or. Efficacy of epidural blood patch with fibrin glue additive. Spontaneous csf leak is a recognized cause of intracranial hypotension, and the syndrome of spontaneous intracranial hypotension has been described as a distinct entity 1 3. Spontaneous intracranial hypotension and the durability of epidural.
Our initial assessment concluded that the diagnosis of sih was not in question. There was, however, some reluctance among the senior anaesthetic staff to perform an ebp for a number of reasons. Spontaneous intracranial hypotension remains an underdiagnosed etiology of newonset headache. It is thought to be due to spontaneous spinal cerebrospinal fluid csf leaks, which probably have a multifactorial etiology. The main of this study is to demonstrate the superiority of the trendelenburg position compared to supine position during 24 hours after an epidural blood patch for a spontaneous intracranial hypotension. The leakage of csf leads to intracranial hypotension of which distinguishing clinical feature is orthostatic headache.
Lumbar and thoracic epidural blood injections to treat. Many patients worry about the procedure, wondering what the whole experience will be like, what to expect and whether or not its painful. Successful treatment was performed with ctguided blood patch at the leakage site after the patient had failed 2 lumbar blood patches. Optimal diagnosis and management of spontaneous intracranial hypotension remains uncertain. Peng skip to main content accessibility help we use cookies to distinguish you from other users and to provide you with a better experience on our websites. Lumbar and thoracic epidural blood injections to treat spontaneous intracranial hypotension you will receive an email whenever this article is corrected, updated, or cited in the literature. 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. Intracranial hypotension, also known as craniospinal hypotension is defined as cerebrospinal fluid csf pressure intracranial hypotension, namely, postural headache, nausea, vomiting, neck pain, visual and hearing disturbances, and vertigo 17. Intracranial hypotension may be spontaneous or related to prior injury, such as brain or spine trauma. Some cases of spontaneous intracranial hypotension resolve with nonoperative measures such as strict bed rest, hydration, or a procedure called an epidural blood patch. Imagingguided precise placement of the blood patch is safe and recommended when a lumbar blood patch away from the leakage site could be ineffective. Spontaneous intracranial hypotension is secondary to a cerebrospinal fluid csf leak at the level of the spine and the resulting loss of csf volume to support the brain and spinal cord.
Rebound intracranial hypertension is a complication of epidural blood patching for treatment of intracranial hypotension characterized by increased intracranial pressure, resulting in potentially severe headache, nausea, and vomiting. Patients with severe signs of postsurgical intracranial hypotension may necessitate immediate treatment with epidural blood patching and placement in the reverse trendelenburg position, as the defect in those cases are likely localized in the lumbar spine e. Spontaneous intracranial hypotension sih is usually treated with an epidural blood patch ebp, but response rates vary and there are no. Injectate volume was variable and guided by the onset of back pain, radiculopathy or symptoms referable to the ebp. Spontaneous intracranial hypotension is a condition in which the fluid pressure inside the skull is lower than normal. In this procedure, the patients own blood is injected into the dural sac. Intracranial hypotension radiology reference article. Men and women of all ages are affected but the diagnosis is more common in women. Spontaneous intracranial hypotension sih manifestations include orthostatic headaches, nausea, vomiting, abducens palsy, and optic neuropathy. A transforaminal approach was also used by schievink et al. Between january 1999 and december 2009, 56 patients who were diagnosed with sih received either a targeted or blind ebp. Alexander a, philip s, varghese p 2016 an epidural blood patch for spontaneous intracranial hypotension a case report. The efficacies of targeted and blind ebps were evaluated based on.
The patient was subsequently referred for an anaesthetic opinion with a view to treatment using an epidural blood patch ebp. Methods ninetyfour patients with sih underwent ebps. The procedure can be done blind or under fluoroscopic or ct guidance, and is performed predominantly by radiologists and anesthesiologists. Spontaneous intracranial hypotension successfully treated. Spontaneous intracranial hypotension treatment siht full. This case report describes the successful treatment of chronic headache from intracranial hypotension with bilateral transforaminal tf lumbar epidural blood patches ebps. In this case report, we have discussed the diagnostic methods of spontaneous intracranial hypotension and the importance of an epidural blood patch for its treatment in the light of the literature. Abstractthirty patients with a typical orthostatic headache were treated by early lumbar epidural blood patch ebp without previously performing lumbar. Spontaneous intracranial hypotension practical neurology. Acquired or secondary intracranial hypotension is less common but has been reported after spinal procedures. The blood circulates throughout the sac and can often patch up the defect until it heals on its own. Spontaneous intracranial hypotension sih is a condition of unknown aetiology, characterised by a postural headache, low cerebrospinal fluid csf pressure due to a csf leak and abnormalities on magnetic resonance imaging mri. The success rates of lumbar blood patch are generally reported to be 70100% 3, 6, 16. Spontaneous intracranial hypotension the spine hospital at.
Evaluation and treatment of spontaneous intracranial hypotension. Efficacy of epidural blood patch in spontaneous intracranial. 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. Once diagnosed with intracranial hypotension, the most common treatment is an epidural patch, in which the patients own blood andor a fibrin glue product is. Typically first epidural blood patches are blind blood patch. Procedural predictors of epidural blood patch efficacy in. Just meaning typically put in lumbar area even though leak location is unknown. Declaration of interests no conflict of interest declared.
Factors predicting response to the first epidural blood patch in. The patient did not show any postural symptoms from the day after treatment. Sih is caused by an atraumatic cerebrospinal fluid csf leak usually secondary to structural dural weakness. Diagnostic criteria for spontaneous spinal csf leaks and. Letters two copies must be typewritten on one side of the paper only and double spaced with wide margins. The procedure can be done blind or under fluoroscopic or ct guidance, and is performed predominantly by radiologists and anes. A generous csf leak was identified at c2 on ct myelography. 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. The epidural blood patch is a goldstandard treatment for intracranial hypotension related orthostatic headaches. Spinal imaging findings in spontaneous intracranial hypotension. Mayo clinic patients with a diagnosis of spontaneous intracranial hypotensioncsf leak from 111996 to 432015 who received epidural blood patch or fibrin glue injection.
Rebound intracranial hypertension sometimes called rebound high pressure and colloquially shortened to rhp can be a complication of epidural blood patching or surgery performed to resolve a csf leak. The leak was later treated by a ctguided blood patch at the c12 level. When the cause cannot be identified, the set of symptoms is referred to as spontaneous cerebrospinal fluid leak syndrome scsfls. Sep 30, 2012 intracranial hypotension syndrome can occur spontaneously. Intracranial hypotension may occur from a tear in the dura caused by trauma, surgery, or lumbar puncture. Intracranial hypotension with severe neurological symptoms. The efficacies of targeted and blind ebps were evaluated. Zada, g, pezeshkian, p, giannotta, s spontaneous intracranial hypotension and immediate improvement following epidural blood patch placement demonstrated by intracranial.
Intracranial hypotension symptoms, treatment, causes. Successful treatment of spontaneous intracranial hypotension. Radiologists play a critical role not only in the diagnosis of this condition, but also in its treatment. Patients with post traumatic and postsurgical cases. Inside the dura is the cerebrospinal fluid csf, a liquid that bathes and cushions the brain and spinal cord. An epidural blood patch is thought to be the most effective. Epidural blood patch is a treatment option for patients with craniospinal hypotension or post lumbar puncture headaches. Spontaneous intracranial hypotension sih remains a rare and difficult clinical entity to diagnose and treat. Cerebrospinal fluid csf leak from the spinal canal. It can be associated with headache, drowsy mentality and intracranial heamorrhage. Two cases including one treated with epidural blood patch pankaj agarwal, suresh menon, rajan shah, 1 and b. Etiology and treatment are straightforward in those settings, since a site of dural disruption is known.
Spontaneous intracranial hypotension sih is a rare syndrome characterized by postural headache associated with a low cerebrospinal fluid pressure in the absence of dural puncture or penetrating. You can manage this and all other alerts in my account. The condition is classically associated with postural headache, which. 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. Epidural blood patch for spontaneous intracranial hypotension. In spontaneous intracranial hypotension due to a cerebrospinal fluid csf leak in which the site has been identified, targeted therapy is indicated when bed rest or medications do not relieve neurological symptoms. Spontaneous intracranial hypotension treated with a targeted ct. When successful, headaches resolve within 72 hours of intervention 12. In recent years, there are some reports of racz catheter use for ebp performance at upper cervical spine levels.
Singhal departments of neurology, bombay hospital institute of medical sciences, mumbai, india. We sought to evaluate the efficacy of ctguided blood patching of observed or potential csf leaks in spontaneous intracranial hypotension. Spontaneous intracranial hypotension in a 37yearold man with intractable headaches was diagnosed on mr imaging. Treatment with epidural blood patch for iatrogenic. Regarding supplements not any that make you heal faster but ones that can be beneficial such as turmeric to. Epidural blood patch, low pressure headache, magnetic resonance imaging, intracranial hypotension introduction spontaneous intracranial hypotension sih is a vexing neurological ailment that often cannot be treated with conservative therapy i. Annual incidence of 5 per 100,000 is likely an underestimate and overall. However, spontaneous intracranial hypotension can recur or be refractory to medical management.
The placement of an epidural blood patch is the most commonly used initial treatment technique for spontaneous intracranial hypotension, and most patients react favorably to an epidural blood patch, even if only temporarily. It was first recognized in 1938 by german neurologist georg schaltenbrand, who described multiple patients presenting with spontaneously occurring low cerebrospinal fluid pressure. Intracranial hypotension syndrome typically occurs spontaneously or iatrogenically. Therefore we concluded the diagnosis as cervical csf leak leading to intracranial hypotension with postural symptoms.
The academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Keywords epidural blood patch, lowpressure headache, spontaneous intracranial hypotension. A case of convexity subarachnoid haemorrhage from intracranial hypotension treated with epidural blood patch enrico ferrante, alberto citterio, luca valvassori, ines arpino, pietro tiraboschi fondazione irccs istituto neurologico c. The aim of this study was to evaluate the efficacies and compare the outcomes of targeted and blind epidural blood patch ebp treatments of spontaneous intracranial hypotension sih. Spontaneous intracranial hypotension nord national. Nov 23, 2004 thirty patients with a typical orthostatic headache were treated by early lumbar epidural blood patch ebp without previously performing lumbar puncture or identifying a csf leak and with or without typical mri changes.
When inferior limb muscles pump blood towards the heart and pressure in the inferior vena cava vein becomes negative, the network of epidural veins is overdrained, causing csf to be aspirated into the epidural space. According to this theory, dural holes and intracranial hypotension are symptoms caused by low venous pressure in the epidural space. The autologous epidural blood patch ebp was first shown to be effective in the treatment of these lowpressure headaches in the 1970s. There are not controlled studies for this treatment. Previously, ebps were performed using anatomical landmarks. An epidural blood patch for spontaneous intracranial. Spontaneous intracranial hypotension sih is characterized by a disabling postural headache in the absence of a dural breech. 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. In some cases, spinal csf leaks can lead to a descent of the cerebellar tonsils into the spinal canal, similar to a chiari malformation. Intracranial hypotension an overview sciencedirect topics. However, because of these varied and sometimes perplexing clinical features of intracranial hypotension, other investigators have proposed additional diagnostic criteria based on brain and spine imaging findings, clinical manifestations, lumbar puncture results, and response to epidural blood patch. The etiology of the headache is due to traction on the dura and vessels at the base of the brain.
The blood patch is thought to seal the leak by causing dural tamponade, preventing ongoing csf volume loss. Spinal leakage of cerebrospinal fluid csf is considered to be the primary cause of spontaneous intracranial hypotension sih. Spontaneous intracranial hypotension sih is an important cause of new daily persistent headache. Because of cerebrospinal fluid csf leak, orthostatic headaches sometimes follow neuraxial blockade or diagnostic lumbar puncture. Aftercare following a csf leak or csf leak repair csf. Imagingguided precise placement of the blood patch is safe and recommended. Early epidural blood patch in spontaneous intracranial hypotension. A patient recently diagnosed with spontaneous intracranial hypotension who also underwent a blood patch for the management of her condition wrote the patient perspective and gave permission for the magnetic resonance imaging scans to be included.
Aftercare following a csf leak or csf leak repair csf leak. Early epidural blood patch in spontaneous intracranial. Dural puncture to measure csf pressure directly is not necessary in patients with positive mri signs of leakage such as dural enhancement with contrast. The patient is a 65yearold male with chronic postural headaches. Blind epidural blood patch for spontaneous intracranial hypotension. A great deal of controversy surrounds the use of an early epidural blood patch ebp in patients with normal mri scans, especially when there is. However, the practical use of racz catheter for singleentry multisite ebp has never been reported until now. Background we report a retrospective analysis of a twolevel, variablevolume epidural blood patch ebp technique for the treatment of spontaneous intracranial hypotension sih. Oct 10, 2014 there are not controlled studies for this treatment. Treatment may include conservative therapy and operation. Spontaneous, sometimes following exertion such as swinging a golf club. Epidural blood patch for the treatment of spontaneous and. He had not had a headachefree day in more than years. Thoracic epidural blood patch for spontaneous intracranial.
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