The efficacy of epidural blood patch in spontaneous csf leaks

Efficacy of epidural blood patch with fibrin glue additive in. Myelogram showing epidural contrast anterior to the cervical thecal sac arrow confirms a cerebrospinal fluid leak from the subarachnoid to epidural space. 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. Methods we retrospectively analysed notes of patients who had an epidural blood patch performed for spontaneous lowpressure headaches in a single centre. The current mainstay of treatment is epidural blood patch ebp that forms a dural tamponade to seal csf leaks by injection of the autologous blood into the spinal epidural space. Spontaneous cervical c1c2 cerebrospinal fluid leakage. Despite recognition that these symptoms are the result of spontaneous spinal csf leaks, patients are grouped under the diagnosis of spontaneous intracranial hypotension.

Best practices in the diagnosis and treatment of spontaneous intracranial hypotension have not yet been determined. Diagnostic criteria for spontaneous spinal csf leaks and. The efficacy of fluoroscopyguided epidural blood patch in. Csf opening pressure is often low but can be within normal limits. The classical description of the aetiology involves csf leakage comparable to that which occurs following an accidental dural puncture during a. An increasing number of factors including iatrogenic factors are realized to involve in development and progression of intracranial hypotension. 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. Mar 08, 2018 we has published new guidance on sensible precautions to consider after an epidural blood patch in consultation with uk neurologists. 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. Regions of dehiscence, usually found on or adjacent to the spinal nerve roots, allow the protrusion of the inner arachnoid layer through the defect in the overlying dura, producing fragile meningeal diverticula that may be prone to tears 7, 10. One study of 42 patients pretreated with acetazolamide who were placed into 30 degrees of trendelenburg both during treatment and 24 hours afterward showed marked and rapid response to ebp. Postepidural blood patch precautions guidance csf leak.

The study described in this article utilizes an analogous technique to gauge the therapeutic reproducibility of this novel technique. The efficacies of targeted and blind ebps were evaluated based on. Mar 11, 2016 injection of fibrin glue mixed with blood into the epidural space to reliably and effectively treat medically refractory orthostatic headache caused by spinal cerebrospinal fluid csf leaks and subsequent intracranial hypotension has recently been described. Although epidural blood patch ebp is considered the goldstandard treatment for drugresistant orthostatic headache in spontaneous intracranial hypotension sih, no clear evidence exists regarding the best administration method of this technique blind vs target procedures.

Epidural blood patches ebp reported a resolution rate of between 50% and 100% for sih. Efficacy of epidural blood patch with fibrin glue additive in refractory. On entering the epidural space a small amount of csf was noted to be dripping from the tuohy needle. The efficacies of targeted and blind ebps were evaluated. Objective to summarize existing evidence regarding the epidemiology, pathophysiology, diagnosis, and. 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 status of diagnosis and treatment to intracranial. Background we report a retrospective analysis of a twolevel, variablevolume epidural blood patch ebp technique for the treatment of spontaneous intracranial hypotension sih.

It affects women more frequently than men, typically in the fourth or fifth decade, but it can also occur in children and the elderly. Etiology and treatment are straightforward in those settings, since a site of dural disruption is known. 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. Furthermore, injected blood volume increases the epidural pressure, which aids in the cessation of csf leakage from the subarachnoid space into the epidural space. Mokri patients should remain flat for three days after the procedure to maximize its chance of success. Fluoroscopyguided epidural blood patch completely resolved symptoms in 85% of postdural puncture 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. Guidelines differ from study to study, and identify who can or cannot participate. We aimed to assess the efficacy of lumbar epidural blood patching in spontaneous, lowpressure headaches. Methods ninetyfour patients with sih underwent ebps. We sought to evaluate the efficacy of ctguided blood patching of observed or potential csf leaks in spontaneous intracranial hypotension. 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. Patients with a spontaneous cerebrospinal fluid leak, normally at a spinal level, typically present with lowpressure headache. The management of cranial and spinal csf leaks barrow.

In spontaneous csf leaks the success rate with each ebp is approximately 30%, while in csf leaks following lumbar puncture, where the exact site is known and the anatomical defect is relatively simple, each ebp has a 90% chance of being effective. Ctguided blood patching has been described but has not been evaluated in larger case series. Epidural patching medical clinical policy bulletins aetna. All fglps and fgebps between january 2014 and may 2017 were retrospectively evaluated. Of 15 patients who received a second ebp, five became asymptomatic 33%. Of eight patients who received three or more ebp mean 4, four patients 50% responded well. Ebp is also effective in relieving symptoms instantaneously in about one third of the patients and thus it may serve a diagnostic purpose 1, 8, 9. Postoperative persistent csf leak may lead to intracranial hypotension ih and positional headaches.

A larger volume of blood 20100 ml may be used in cases that fail to respond to the initial. Leakage detection on ct myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks. Duke is one of only three centers in the country that has been working continuously on this problem over the past ten. Stigmata of disorders of connective tissue matrix are seen in some of the patients. It is an important cause of new headaches in young and middleaged individuals, but initial misdiagnosis is common.

Postoperative persistent csf leak may lead to intracranial hypotension ih and positional. Evidence of spinal csf leak may be shown by spine mri, computed tomography myelography ctm, or both. It is now recognized that nearly all cases of sih result from spontaneous csf leaks, which occur at the level of the spine inamasu and guiot 2006. Participant eligibility includes age, gender, type and stage of disease, and previous treatments or health concerns. Largevolume lumbar epidural blood patches, an approach adapted from the treatment of postlumbar puncture headache, are often used for treatment of spontaneous intracranial hypotension and can be effective immediately. Management of cerebrospinal fluid csf leak during minimally invasive lumbar tubular microdiscectomy poses challenges unique to the surgical approach. Focal dural thinning and dehiscence are common causes of spontaneous csf leak. Cureus early epidural blood patch to treat intracranial. Other causes of csf leaks may be due to surgery or trauma. Evidence of spinal csf leak may be shown by spine mri, computed. A second cervical epidural blood patch was performed, and the patient has been headachefree for nearly one year to date. The mainstay of treatment is the injection of autologous blood into the spinal epidural space, the socalled epidural blood patch. The objective of this study is to evaluate the efficacy of epidural blood patch ebp in spontaneous csf leaks.

Cranial magnetic resonance imaging in spontaneous intracranial. The epidural blood patch was repeated through the caudal space and was again immediately successful, enabling the patient to return to work. 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. This technique effectively seals the csf leak in about onethird of sih patients in whom the epidural blood patch was ineffective schievink et al. Cerebrospinal fluid csf leaks clinical trials mayo clinic. An epidural blood patch for spontaneous intracranial hypotension. Editorspontaneous intracranial hypotension sih is an important, but rare, cause of new onset persistent headaches. Pdf background and objective epidural blood patch ebp is a safe and effective treatment for spontaneous intracranial hypotension sih, but clinical. 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. Of 25 consecutive patients with spontaneous csf leaks treated with epidural blood patch ebp, nine patients 36% responded well to the first ebp. Cranial magnetic resonance imaging in spontaneous intracranial hypotension after epidural blood patch. The vertebral space where the ebp was performed is depicted in figure 2. To evaluate patient outcomes following fluoroscopyguided epidural blood patch fgebp, factors affecting the outcome, and to identify the rate of fluoroscopyguided lumbar punctures fglp requiring fgebp. Nov 28, 2019 an epidural blood patch ebp is now considered the treatment of first choice for spinal csf leakage in those patients who have not responded to initial conservative management.

Intracranial hypotension, especially spontaneous intracranial hypotension sih, is a wellrecognized entity associated with cerebrospinal fluid csf leaks, and has being recognized better in resent years, while still woefully inadequate. Spontaneous intracranial hypotension sih is an important cause of new daily persistent headache. Key factors determine success of epidural patch for csf leaks. The classic manifestation of sih is an orthostatic headache, but other neurological symptoms may be present. This was felt to be consistent with a diagnosis of sih and not the result of an accidental dural puncture. Context spontaneous intracranial hypotension is caused by spontaneous spinal cerebrospinal fluid csf leaks and is known for causing orthostatic headaches.

Efficacy of epidural blood patch in spontaneous intracranial. Epidural blood patch was performed after a median delay of 4 days range, 153 days after dural puncture. Epidural blood patch ebp has emerged as the most important nonsurgical treatment for spontaneous csf leaks. Efficacy of epidural blood patch with fibrin glue additive. The success approaches 95% when including the patients with partial resolution of symptoms. This difference may be related to the fact that, with spontaneous csf leaks, the level of the epidural blood patch may be distant from the level of the leak, and in many spontaneous csf leaks the nature and anatomy of the leak are much different from those of a simple hole or rent produced by the spinal tap needle. Predictors of the response to an epidural blood patch in. Blind epidural blood patch for spontaneous intracranial hypotension. Effectiveness of epidural blood patch in the management of. Optimal diagnosis and management of spontaneous intracranial hypotension remains uncertain. Spontaneous intracranial hypotension treatment siht siht. Of 25 consecutive patients with spontaneous csf leaks treated with epidural blood patch ebp, nine patients 36% responded well to the first. An epidural blood patch ebp is now considered the treatment of first choice for spinal csf leakage in those patients who have not responded to initial conservative management.

Methods we retrospectively analysed notes of patients who had an epidural blood patch performed for spontaneous low. Injectate volume was variable and guided by the onset of back pain, radiculopathy or symptoms referable to the ebp. Spontaneous intracranial hypotension treated with a. Efficacy of epidural blood patch in spontaneous intracranial hypotension csf leak rochester, mn the objective of this study is to evaluate the efficacy of epidural blood patch ebp in spontaneous csf leaks. Primary repair can be limited via tubular retractor systems, and onlay graft and dural sealant are often the treatment of choice intraoperatively. Total spinal epidural blood patch application through a. Epidural blood patch an overview sciencedirect topics. Blind epidural blood patch for spontaneous intracranial.

Pdf procedural predictors of epidural blood patch efficacy. This type of patch is referred to as a blind or nontargeted or nondirected epidural blood patch ebp because the procedure involves the injection of the patients own blood into the spinal epidural space without knowledge of the level of the site of the leak. Spontaneous spinal cerebrospinal fluid leaks and intracranial. Spontaneous csf leak at the level of skull base does occur but only rarely. The autologous epidural blood patch ebp was first shown to be effective in the treatment of these lowpressure headaches in the 1970s. The leaflet 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, however we would strongly encourage you to seek and follow advice from your own doctor.

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. Spontaneous intracranial hypotension treatment siht. Previously, the only set of diagnostic criteria for spontaneous spinal csf leak and intracranial hypotension were those published by the icdh2. Successful treatment of spontaneous intracranial hypotension. Injection of fibrin glue mixed with blood into the epidural space to reliably and effectively treat medically refractory orthostatic headache caused by spinal cerebrospinal fluid csf leaks and subsequent intracranial hypotension has recently been described.

Intracranial hypotension headache after uncomplicated. The efficacy of epidural blood patch in spontaneous csf leaks. Spontaneous intracranial hypotension treated with a targeted. Spontaneous intracranial hypotension guidelines development. Information regarding patient characteristics, details of previous dural puncture dp. Procedural predictors of epidural blood patch efficacy in. This quickly led to resolution of the headache and cranial nerve palsies, and later to the complete resolution of his sdh. We has published new guidance on sensible precautions to consider after an epidural blood patch in consultation with uk neurologists.

An epidural blood patch, once or more, targeted or distant, at one site or bilevel, has emerged as the treatment of choice for those who have failed the conservative measures. Factors predicting response to the first epidural blood patch in. Ctguided epidural blood patching of directly observed or. Between january 1999 and december 2009, 56 patients who were diagnosed with sih received either a targeted or blind ebp. 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. It is thought to be due to spontaneous spinal cerebrospinal fluid csf leaks, which probably have a multifactorial etiology. Cerebrospinal fluid csf leaks clinical trials mayo. An epidural blood patch is thought to be the most effective. Early epidural blood patch in spontaneous intracranial hypotension.