The blood patch is thought to seal the leak by causing dural tamponade, preventing ongoing csf volume loss. Patients with post traumatic and postsurgical cases. Because the symptoms of rebound intracranial hypertension may bear some similarity to those of intracranial hypotension and literature reports of. Two cases including one treated with epidural blood patch pankaj agarwal, suresh menon, rajan shah, 1 and b. 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. Just meaning typically put in lumbar area even though leak location is unknown. Spontaneous intracranial hypotension sih is rare, often misdiagnosed, as a cause of postural headaches. Successful treatment was performed with ctguided blood patch at the leakage site after the patient had failed 2 lumbar blood patches. Multiple imaging modalities may be used in defining this disease, and following the. 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. It is thought to be due to spontaneous spinal cerebrospinal fluid csf leaks, which probably have a multifactorial etiology. 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.
The autologous epidural blood patch ebp was first shown to be effective in the treatment of these lowpressure headaches in the 1970s. The headache associated with intracranial hypotension typically improves while the patient is recumbent and worsens upon sitting or standing. Iatrogenic intracranial hypotension can occur due to dural pucture, trauma and spine surgery. It was first recognized in 1938 by german neurologist georg schaltenbrand, who described multiple patients presenting with spontaneously occurring low cerebrospinal fluid pressure. 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. A generous csf leak was identified at c2 on ct myelography. Diagnostic criteria for spontaneous spinal csf leaks and. Total spinal epidural blood patch application through a. Ctguided epidural blood patching of directly observed or. Efficacy of epidural blood patch with fibrin glue additive in refractory headache due to intracranial hypotension.
The injury may be iatrogenic such as in cases of intracranial hypotension that develop as a sequela of lumbar puncture or surgery along the neuroaxis. The procedure can be done blind or under fluoroscopic or ct guidance, and is performed predominantly by radiologists and anesthesiologists. 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. Epidural blood patch for the treatment of spontaneous and. An epidural blood patch is thought to be the most effective. Spontaneous intracranial hypotension nord national. Sep 30, 2012 intracranial hypotension syndrome can occur spontaneously. Transforaminal blood patch for the treatment of chronic. There are not controlled studies for this treatment. Spontaneous intracranial hypotension the spine hospital. 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 sih is usually treated with an epidural blood patch ebp, but response rates vary and there are no. 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. How patients were involved in the creation of this article.
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. Between january 1999 and december 2009, 56 patients who were diagnosed with sih received either a targeted or blind ebp. Men and women of all ages are affected but the diagnosis is more common in women. Spinal leakage of cerebrospinal fluid csf is considered to be the primary cause of spontaneous intracranial hypotension sih. An epidural blood patch for spontaneous intracranial. However, spontaneous intracranial hypotension can recur or be refractory to medical management. 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 syndrome typically occurs spontaneously or iatrogenically. Efficacy of epidural blood patch with fibrin glue additive. Declaration of interests no conflict of interest declared. Spontaneous intracranial hypotension sih is characterized by a disabling postural headache in the absence of a dural breech. Ctguided blood patching has been described but has not been evaluated in larger case series. 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. Intracranial hypotension radiology reference article. 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. 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. Our initial assessment concluded that the diagnosis of sih was not in question. Injectate volume was variable and guided by the onset of back pain, radiculopathy or symptoms referable to the ebp. Sih is caused by an atraumatic cerebrospinal fluid csf leak usually secondary to structural dural weakness.
Spontaneous intracranial hypotension and the durability of epidural. Spontaneous intracranial hypotension with typical orthostatic headache can be diagnosed. Abstractthirty patients with a typical orthostatic headache were treated by early lumbar epidural blood patch ebp without previously performing lumbar. Early epidural blood patch in spontaneous intracranial. 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. 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. 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.
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. The blood circulates throughout the sac and can often patch up the defect until it heals on its own. 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. Spontaneous, sometimes following exertion such as swinging a golf club. The procedure can be done blind or under fluoroscopic or ct guidance, and is performed predominantly by radiologists and anes. The etiology of the headache is due to traction on the dura and vessels at the base of the brain. Spontaneous intracranial hypotension sih remains a rare and difficult clinical entity to diagnose and treat. The brain and spinal cord are covered by a tough, watertight membrane called the dura. Therefore we concluded the diagnosis as cervical csf leak leading to intracranial hypotension with postural symptoms. Factors predicting response to the first epidural blood patch in. Regarding supplements not any that make you heal faster but ones that can be beneficial such as turmeric to. Many patients worry about the procedure, wondering what the whole experience will be like, what to expect and whether or not its painful.
Intracranial hypotension can be defined as a medical condition, in which the pressure within the brain cavity is negative. Spontaneous intracranial hypotension treated with a. Zada, g, pezeshkian, p, giannotta, s spontaneous intracranial hypotension and immediate improvement following epidural blood patch placement demonstrated by intracranial. However, the practical use of racz catheter for singleentry multisite ebp has never been reported until now. Procedural predictors of epidural blood patch efficacy in. It is characterised by increased intracranial pressure, resulting in potentially severe headache, nausea, and vomiting. The efficacies of targeted and blind ebps were evaluated.
We present a 37yearold man who developed a 4 week duration postural headache without sustaining significant trauma. When the cause cannot be identified, the set of symptoms is referred to as spontaneous cerebrospinal fluid leak syndrome scsfls. Blood patch therapy for spontaneous intracranial hypotension. In recent years, there are some reports of racz catheter use for ebp performance at upper cervical spine levels. This case report describes the successful treatment of chronic headache from intracranial hypotension with bilateral transforaminal tf lumbar epidural blood patches ebps. Successful treatment of spontaneous intracranial hypotension. Previously, ebps were performed using anatomical landmarks. The patient did not show any postural symptoms from the day after treatment. The patient is a 65yearold male with chronic postural headaches. Keywords epidural blood patch, lowpressure headache, spontaneous intracranial hypotension. 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. 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. Thoracic epidural blood patch for spontaneous intracranial. 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.
Cervical dural csf leak on mri and ct treated by blood patch. There was, however, some reluctance among the senior anaesthetic staff to perform an ebp for a number of reasons. 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. Spontaneous intracranial hypotension practical neurology. He had not had a headachefree day in more than years. Epidural blood patch ebp is a standard treatment of spontaneous intracranial hypotension sih. Etiology and treatment are straightforward in those settings, since a site of dural disruption is known. The leak was later treated by a ctguided blood patch at the c12 level. 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.
Spontaneous intracranial hypotension in a 37yearold man with intractable headaches was diagnosed on mr imaging. 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 an unusual clinical entity in which patients often present with a spectrum of clinical signs and symptoms. Spontaneous intracranial hypotension sih manifestations include orthostatic headaches, nausea, vomiting, abducens palsy, and optic neuropathy. Spontaneous intracranial hypotension treated with a targeted. Early epidural blood patch in spontaneous intracranial hypotension neurology. Blind epidural blood patch for spontaneous intracranial hypotension. Low pressure headaches caused by spontaneous intracranial. Alexander a, philip s, varghese p 2016 an epidural blood patch for spontaneous intracranial hypotension a case report. Spontaneous intracranial hypotension treated with a targeted ct. An epidural blood patch is thought to be the most effective treatment, but a blind infusion may be ineffective. In the majority of the cases, the intracranial hypotension has a spontaneous onset, leading to an alteration in the balance of intracranial blood, cerebrospinal fluid and brain tissue. 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. In this procedure, the patients own blood is injected into the dural sac.
Her comments on the draft manuscript have been incorporated in the revised paper. Methods ninetyfour patients with sih underwent ebps. 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. Spontaneous intracranial hypotension the spine hospital at.
Intracranial hypotension an overview sciencedirect topics. Efficacy of epidural blood patch in spontaneous intracranial. Aftercare following a csf leak or csf leak repair csf. Intracranial hypotension may be spontaneous or related to prior injury, such as brain or spine trauma. Treatment may include conservative therapy and operation. Lumbar and thoracic epidural blood injections to treat. According to this theory, dural holes and intracranial hypotension are symptoms caused by low venous pressure in the epidural space.
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. Because of cerebrospinal fluid csf leak, orthostatic headaches sometimes follow neuraxial blockade or diagnostic lumbar puncture. Optimal diagnosis and management of spontaneous intracranial hypotension remains uncertain. The classic manifestation of sih is an orthostatic headache, but other neurological symptoms may be present. The leakage of csf leads to intracranial hypotension of which distinguishing clinical feature is orthostatic headache. You can manage this and all other alerts in my account. Evaluation and treatment of spontaneous intracranial hypotension. 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. 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. Early epidural blood patch in spontaneous intracranial hypotension. Epidural blood patch for spontaneous intracranial hypotension. Intracranial hypotension symptoms, treatment, causes.
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 patient was subsequently referred for an anaesthetic opinion with a view to treatment using an epidural blood patch ebp. 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 condition is classically associated with postural headache, which. We sought to evaluate the efficacy of ctguided blood patching of observed or potential csf leaks in spontaneous intracranial hypotension.
Epidural blood patch is a treatment option for patients with craniospinal hypotension or post lumbar puncture headaches. Annual incidence of 5 per 100,000 is likely an underestimate and overall. In some cases, spinal csf leaks can lead to a descent of the cerebellar tonsils into the spinal canal, similar to a chiari malformation. Spontaneous intracranial hypotension is a condition in which the fluid pressure inside the skull is lower than normal. Spontaneous intracranial hypotension treatment siht. Cerebrospinal fluid csf leak from the spinal canal. Treatment with epidural blood patch for iatrogenic. The efficacies of targeted and blind ebps were evaluated based on. Some cases of spontaneous intracranial hypotension resolve with nonoperative measures such as strict bed rest, hydration, or a procedure called an epidural blood patch. The epidural blood patch is a goldstandard treatment for intracranial hypotension related orthostatic headaches. Spontaneous intracranial hypotension sih is an important cause of new daily persistent headache. Intracranial hypotension with severe neurological symptoms. Dural puncture to measure csf pressure directly is not necessary in patients with positive mri signs of leakage such as dural enhancement with contrast. Blind epidural blood patch for spontaneous intracranial.
Background we report a retrospective analysis of a twolevel, variablevolume epidural blood patch ebp technique for the treatment of spontaneous intracranial hypotension sih. Mayo clinic patients with a diagnosis of spontaneous intracranial hypotensioncsf leak from 111996 to 432015 who received epidural blood patch or fibrin glue injection. Epidural blood patch for spontaneous intracranial hypotension with. Spontaneous intracranial hypotension treatment siht full. When successful, headaches resolve within 72 hours of intervention 12. Imagingguided precise placement of the blood patch is safe and recommended when a lumbar blood patch away from the leakage site could be ineffective. It can be associated with headache, drowsy mentality and intracranial heamorrhage. A transforaminal approach was also used by schievink et al. Radiologists play a critical role not only in the diagnosis of this condition, but also in its treatment.
Spontaneous intracranial hypotension remains an underdiagnosed etiology of newonset headache. All correspondence should be addressed to dr david bogod, editor of anaesthesia, ist floor, maternity unit, nottingham city hospital, hucknall. Intracranial hypotension is a condition in which there is negative pressure within the brain cavity. Typically first epidural blood patches are blind blood patch. Inside the dura is the cerebrospinal fluid csf, a liquid that bathes and cushions the brain and spinal cord. Oct 10, 2014 there are not controlled studies for this treatment.
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. 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. Singhal departments of neurology, bombay hospital institute of medical sciences, mumbai, india. Intracranial hypotension may occur from a tear in the dura caused by trauma, surgery, or lumbar puncture. Intracranial hypotension with severe neurological symptoms resolved by epidural blood patch volume 31 issue 4 philip w. Thoracic epidural blood patch for spontaneous intracranial hypotension. 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.
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