Blind epidural blood patch for spontaneous intracranial. In the following 20 months i actively sought medical treatment for. 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. My spontaneous leak first started on 32720 and i was diagnosed with spontaneous csf leak on 32920 after mri showed fluid pooled. 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. A case of spontaneous cerebrospinal fluid csf leak from a sacral nerve root sleeve is reported. Spinal leakage of cerebrospinal fluid csf is considered to be the. When epidural blood patching is unsuccessful or if symptoms recur, spinal imaging findings help to guide further treatment. In this procedure, your own blood is injected into the spinal canal.
Cerebrospinal fluid csf leak management and treatment. Successful treatment of spontaneous cerebrospinal fluid leak headache with fluoroscopically guided epidural blood patch. Treatment for a csf leak depends on the type and location of any hole or tear, as well as the underlying cause. With a postdural puncture headache, a patient usually has a single leak site in the dorsal dura. Cervical epidural blood patch for low csf pressure.
For spinal csf leaks that do not respond to bed rest and other conservative treatments, an epidural blood patch or epidural patching with fibrin glue are treatment options. Other treatments have been suggested with different success rates, including intrathecal fluid infusion, epidural saline infusion, epidural infusion of dextran, epidural injection of fibrin glue, csf shunting, and surgical repair of the leak. Evaluation and treatment of spontaneous intracranial hypotension. The most common intervention to resolve a spinal csf leak that hasnt resolved on its own is an epidural blood patch. Epidural patch with fibrin sealant fibrin sealant is a pooled blood product which has been treated with a twostep process to reduce the risk of viral transmission. The vertebral space where the ebp was performed is depicted in figure 2.
It is thought to be due to spontaneous spinal cerebrospinal fluid csf leaks, which. Invasive treatment may include nontargeted also referred to as empiric and targeted epidural blood patches, where a patients blood is drawn and immediately injected into the epidural space. Fibrin sealant can occasionally result in allergic anaphylactic reactions but pretreatment with medication reduces that risk. Almost all cases of sih are a result of spontaneous spinal csf leakage from spinal meningeal diverticula or simple dural tears. An epidural blood patch, where blood is drawn from the patient and immediately injected into the epidural space, is the most common invasive treatment for spinal. Thoracic blood patch, partial success spinal csf leak. Duke is one of only three centers in the country that has been working continuously on this problem over the past ten. Blood patch your own blood or, in some cases, a type of glue is used to create a patch that seals the leak.
Transforaminal blood patch for the treatment of chronic. This patient received two lumbar epidural blood patches without lasting relief. A recent report suggested epidural fibrin glue application should epidural blood patching fail 23. If several attempts of epidural blood patches do not work, other grafting materials, such as epidural fibrin glue, or fat or muscle patches, may be tried. Total spinal epidural blood patch application through a. Using a transforaminal approach allowed for placement of blood directly at the presumed site of csf leak when an interlaminar approach was not practical because of a previous laminectomy. Treatment csf leak association cerebrospinal fluid leak and. Information on this site is provided in good faith and is intended to.
If symptoms persist with conservative management, another treatment method shown to be effective is epidural blood patching, in which the patients own blood in the amount of approximately 1020ml is used to replace the volume lost from csf as well as serve as a sealant at the site from which csf is leaking. If these methods are not successful, other surgical approaches to repair the leak include. Based on the successful treatment of this patients spontaneous intracranial hypotension, we advocate that patients undergo epidural blood patches to target the site of any csf leak identified by. The patient was subsequently referred for an anaesthetic opinion with a view to treatment using an epidural blood patch ebp. An epidural blood patch is a surgical procedure that provides immediate relief to the headache caused by leaking spinal fluid. We present a case of successful treatment of chronic headache secondary to sih using a transforaminal epidural blood patch figures figures1 1 and and2.
Blood is taken from your arm and injected into an area of your spinal canal to patch the leak. Our initial assessment concluded that the diagnosis of sih was not in question. Early epidural blood patch in spontaneous intracranial hypotension. The blood clot that forms creates a seal to stop the leak.
Schievink, md, discusses symptoms, diagnosis, treatment and prognosis for patients. Spinal imaging is recommended if such treatments fail or if cranial mr imaging is normal. 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. Conservative bed rest hydration 23 litres per day iv caffeine infusions strong coffee or caffeine tablets invasive an epidural blood patch, where blood is drawn.
Epidural blood patch ebp has emerged as the most important nonsurgical treatment for spontaneous csf leaks. When to suspect a csf leak in patients with headache. Treatment is directed at identifying the site of the fistula and treating the underlying cause i. Deepak demonstrate the process of administering an epidural blood patch for spontaneous csf leak from the lumbar area. Approximately 1520 mls of blood is taken from a vein in the patients arm and subsequently injected into the epidural space in the spine at the site of the spinal fluid leak. 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. 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. 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. Low csf pressure headache is divided by the international headache society into three categories. In our practice, epidural blood patching or conservative treatment consisting of bed rest, oral hydration, and oral caffeine is recommended after cranial mr imaging confirms the clinical suspicion of spontaneous intracranial hypotension.
Spinal cerebrospinal fluid csf leak brain foundation. Patients with post traumatic and postsurgical cases. A spontaneous csf leak and the clinical syndrome that it causes may be confused with a postdural puncture headache. The blood andor glue is injected adjacent to the tear or potential site of the leak under ct fluoroscopic guidance. Blood patch for spontaneous intracranial hypotension. Epidural blood patch was performed after a median delay of 4 days range, 153 days after dural puncture. Successful treatment of spontaneous cerebrospinal fluid. Aftercare following a csf leak or csf leak repair csf. 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. Although well described from other parts of the world, there exists a remarkable paucity of reports of sih from india. The exact site of csf leak could not be identified.
Spontaneous intracranial hypotension sih is a rare condition due to a spontaneous cerebrospinal fluid csf leak into the epidural space and is clinically manifested by orthostatic headache. In anesthetic practice, ebp at the leakage site is the treatment of choice if conservative measures have failed. Key factors determine success of epidural patch for csf leaks. A directed epidural blood patch, placed in close proximity to the level of suspected csf leak, is effective in most patients. The diagnosis of spontaneous csf leak can be very challenging, but increasing awareness and improved diagnostic techniques are yielding ever more cases. The leak resulted in csf hypotension, which failed to resolve with prolonged bed rest. Treatment csf leak association cerebrospinal fluid.
Abstract patients with a spontaneous cerebrospinal fluid leak, normally at a. Sc046319 promoting awareness of cerebrospinal fluid csf leaks, with a particular focus on spinal csf leaks. In one 2016 study, researchers compared the success rates of epidural blood patches in 3 people with csf. When epidural blood patching is unsuccessful or if symptoms recur, spinal imaging. Epidural patching with fibrin sealant may be directed at the leak location or a surgical repair may be the best option. Online patient forum provides platform for program director to share his extensive knowledge with those who need it most. It is thought to be due to spontaneous spinal cerebrospinal fluid csf leaks, which probably have a multifactorial etiology. Click on the postcard to download a copy suitable for sharing on social media. Spinal cerebrospinal fluid csf leak, also known as spontaneous intracranial hypotension is a debilitating medical condition as a result of this leakage, patients with this condition suffer from debilitating headaches. The first line of treatment for csf leaks is epidural blood patching used to treat postdural puncture headache pph. Where the leak site is known, blood will be injected as close to it as possible. Spontaneous intracranial hypotension treated with a. Epidural blood patch for spontaneous intracranial hypotension with.
The management of cranial and spinal csf leaks barrow. Sih with a csf leak at the upper cervical spine may be least amenable to conventional epidural blood patch delivered from the lumbar spine. Treatment of spontaneous cerebrospinal fluid leak with. Most common sites of csf leaks are at the cervicothoracic or thoracolumbar junctions. A blood patch is a medical procedure that is used to close cerebral spinal fluid csf leaks. Diagnostic criteria for spontaneous spinal csf leaks and. After conservative treatments have been tried, an epidural blood patch is the most common treatment for spinal csf leaks. A generous csf leak was identified at c2 on ct myelography.
Sih is typically the result of spontaneous cerebral spinal fluid csf leak at the spine level. Surgical repairs of spinal csf leaks have good success rates in the hands of. Surgical repair of spinal csf leaks have good success rates in the hands of experienced neurosurgeons. Where a leak is suspected initial treatment includes bed rest, fluids and extra caffeine. Spontaneous intracranial hypotension nord national. Epidural blood or fibrin patch is the treatment of choice for sih. The resulting blood clot then patches the hole where the leak is occurring. The precise manner in which an epidural blood patch ebp is helpful is not. When conservative management fails, the pain management clinician is called upon to administer an epidural blood patch. Complexities of low csf volume headache mayo clinic. An epidural blood patch is thought to be the most effective. If the precise location isnt known, one or more patches may be placed.
It is important to note that there are no absolute right or wrongs when it comes to what you shouldshould not do following a blood patch, nor how. Successful treatment of spontaneous cerebrospinal fluid leak. An epidural blood patch, where blood is drawn from the patient and immediately injected into the epidural space, is the most common invasive treatment for spinal leaks. For most patients, spinal imaging to localize their spinal csf leak may not be necessary, because 12 epidural blood patch procedures will be curative. Although these patches are a safe and effective treatment for spontaneous csf hypovolemia, clinical and procedural variables predictive of. Effectiveness of epidural blood patch in the management of. An epidural blood patch is thought to be the most effective treatment, but a. There is up to a 90% response to a single epidural blood patch. An epidural blood patch involves injecting the patients own blood into the spinal canal. The csf leak association is a scottish charitable incorporated organisation charity no. A common treatment is something called an epidural blood patch, which tries to stop your csf leak. A range of specialized spinal imaging techniques, including computed tomography ct, magnetic resonance mr, and digital subtraction are used to locate a spinal csf leak. Spontaneous intracranial hypotension treated with a targeted ct. Sdh with sih that was treated with epidural blood patching ebp.
Although response time in pph is usually immediate, it often takes longer in sih. Other causes of csf leaks may be due to surgery or trauma. If symptoms recur, a repeat procedure may be performed. 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 cerebrospinal fluid csf leakage could be happened spontaneously or related to the procedures such as spinal anesthesia, epidural. Spontaneous intracranial hypotension sih is an important cause of new daily persistent headache. An epidural blood patch using autologous blood placed percutaneously via the caudal canal was successful in treating the problem. Successful treatment was performed with ctguided blood patch at the leakage site after the patient had failed 2 lumbar blood patches. Epidural blood patch for the treatment of spontaneous and. Imagingguided precise placement of the blood patch is safe and recommended when a lumbar blood patch away from the leakage site could be ineffective. The classic manifestation of sih is an orthostatic headache, but other neurological symptoms may be present. Mokri patients should remain flat for three days after the procedure to maximize its chance of success.
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