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Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 416-418  

A single-level epidural blood patch for multiple cerebrospinal fluid leaks: How it works


1 Department of Anaesthesiology, Tata Main Hospital, Jamshedpur, Jharkhand, India
2 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission15-Aug-2022
Date of Acceptance13-Sep-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Dr. Amlan Swain
Department of Anaesthesia and Critical Care, Tata Main Hospital, Northern Town, Bistupur, Jamshedpur - 830 001, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.aer_131_22

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   Abstract 

Spontaneous intracranial hypotension caused by cerebrospinal fluid (CSF) leak is a rarely encountered cause of persistent postural headaches in the absence of trauma or dural puncture. It presents with postural headache and is characterized by radiological findings of spinal CSF leak. The mainstay of management is an epidural patch with the patient's own blood (epidural blood patch [EBP]) and/or a fibrin glue product. We report here a case of spontaneous intracranial hemorrhage presenting with persistent headaches and bilateral subdural hematomas secondary to CSF leaks at multiple levels along the spinal cord, which was successfully managed with a single lumbar EBP.

Keywords: Cerebrospinal fluid leak, epidural blood patch, spontaneous intracranial hypotension


How to cite this article:
Swain A, Sahu S, Kumari R, Tripathi M. A single-level epidural blood patch for multiple cerebrospinal fluid leaks: How it works. Anesth Essays Res 2022;16:416-8

How to cite this URL:
Swain A, Sahu S, Kumari R, Tripathi M. A single-level epidural blood patch for multiple cerebrospinal fluid leaks: How it works. Anesth Essays Res [serial online] 2022 [cited 2023 Feb 3];16:416-8. Available from: https://www.aeronline.org/text.asp?2022/16/3/416/363132


   Introduction Top


Spontaneous intracranial hypotension (SIH) is a rare cause of persistent postural headaches characterized by radiological findings of cerebrospinal fluid (CSF) leak and the absence of discernible cause such as trauma or dural puncture and is treated with an epidural patch.[1],[2],[3],[4] We hereby report a case of spontaneous intracranial hemorrhage secondary to CSF leaks at multiple levels along the spinal cord who was successfully managed with a single lumbar epidural blood patch (EBP).


   Case Report Top


A 40-year-old diabetic male presented to our hospital with a history of recurrent headaches for the past 15 days associated with one episode of vomiting. There was no neurological deficit, giddiness, seizure, or history of head injury. Initial computed tomography (CT) scans revealed a bilateral subdural hematoma (SDH). He was on cerebral decongestant medication (dexamethasone 2 mg TDS, mannitol 100 ml, and phenytoin 100 mg TDS) and analgesics for headaches. A subsequent CT myelogram revealed extrathecal extravasation of contrast material bilaterally at C5-C6, D1-D2, D12-L1, and L2-L3 intravertebral levels and on the left side at D8-D9, L1-L2, and L5-S1 intravertebral level, which unequivocally established a CSF leak [Figure 1] and [Figure 2]. A diagnosis of SIH secondary to a CSF leak was made. He was scheduled for an EBP procedure for the CSF leak along with conservative management of the SDH owing to its small size as it was deemed to be a secondary presentation of the CSF leak. His physical examination in the preoperative visit was remarkable for a reduction in the plantar reflex. All other routine investigations were normal. Written informed consent was obtained from the patient and his family members after an informed discussion about an EBP. On the day of the intervention, under all aseptic precautions and in an upright sitting position, an 18G Tuohy epidural needle was introduced at the L2-L3 intervertebral level and the epidural space was identified using the loss of resistance technique. Twenty-five milliliters of autologous blood from the patient was drawn simultaneously from his right cephalic vein by an assistant and injected slowly into the epidural space till the patient started experiencing a stretching sensation in the back. He was made supine; a slight Trendelenburg position was maintained for another 20 min in the operating room and he was then shifted to the postanesthesia care unit for observation. The vitals were stable during the entire periprocedure duration. He was advised strict bed rest along with steroids (intravenous dexamethasone) and caffeine-containing drinks for 48 h. The rest of the postprocedural course was uneventful. The patient was followed up till discharge every day and thereafter in the neurology outpatient department every fortnightly for 2 months. The patient had relief from his debilitating headache as early as 12-h postprocedure. He did not have a relapse of symptoms and returned to the normal level of physical activity after a fortnight.
Figure 1: CT myelogram of the spine – coronal section – showing CSF leak at multiple levels at (a) L1-L2 level and (b) L2-L3 level of the spinal vertebra. CT = Computed tomography, CSF = Cerebrospinal fluid, D = Dorsal spinal vertebra, L = Lumbar spinal vertebra

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Figure 2: CT myelogram of spine – axial view – showing CSF leak at multiple levels (a) at D5-D6 level, (b) at D11-D12 level, (c) at D12-L1 level, and (d) at L5-S1 level of spinal vertebrae. CT = Computed tomography, CSF = Cerebrospinal fluid, D = Dorsal spinal vertebra, L = Lumbar spinal vertebra, S = Sacral spinal vertebra

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   Discussion Top


SIH is an infrequent disease with varied presentation caused by CSF leak and is a treatable cause of persistent postural headaches.[1] Due to its relative infrequency, the diagnosis is rarely made on the first physician encounter and can be misdiagnosed.[2] Many methods have been proposed to evaluate potential causes of low pressure; however, there is currently no universal consensus on the best method to diagnose SIH. Although challenging, spine imaging, including magnetic resonance imaging (MRI), CT or MRI myelography, or cisternography is often performed to investigate the source of the suspected leak.[2] Interestingly, the presence of bilateral SDH caused confusion in the initial workup in our patient, and only after the confirmatory findings of CSF leak at multiple levels in the CT myelogram, the diagnosis was clinched.

The most common treatment of SIH includes an epidural patch, in which the patient's own blood and/or a fibrin glue product is injected into the epidural space.[4],[5] This can be performed either based on only anatomical landmarks or with imaging guidance taking care to perform the procedure as close to the suspected site of the leak as possible.[4] Patients respond well to blood patches at single or multiple levels, particularly if the site of the leak is localized; some may go on to require multiple sittings of EBP.[6] Most refractory patients ultimately require surgical treatment.[3],[7] In our patient, multiple sites of the leak were identified with a greater concentration of leaks in the lumbar area, steering the decision in favor of a lumbar EBP. It was based on the understanding that a lumbar patch is usually effective and relatively safe compared to local blood patches for more proximal CSF leaks.[8] The therapeutic effect of a distal blood patch in multiple leaks likely results from the combination of an initial tamponade effect followed by plugging of the CSF leak by blood moving proximally through the epidural space to assist the formation of a fibrin “plug”. The rostral spread of CSF aiding our therapeutic effect has been attributed to the negative pressure gradient demonstrated by various authors.[8] N-Butyl cyanoacrylate in the epidural space has also shown encouraging results.[5]

We performed the blood patch with 25 mL of blood (blood volume more than 20 mL), supported by the presumption that larger blood volumes for EBP were associated with a higher success rate in a recent study conducted by Wu et al.[9] In addition, we kept our patient initially upright, followed by the Trendelenburg position to augment the rostrum spread of blood in CSF based on evidence of the same in recent studies.[8],[10] We believe that the rostral spread of an appropriate amount of blood injected close to the site with maximum leaks (lumbar epidural space) and a postprocedure Trendelenburg position helped us achieve complete relief of symptoms in our patient.[10]


   Conclusion Top


We conclude that SIH is an often misdiagnosed entity with a plethora of treatment options. Even in cases wherein there is a CSF leak at multiple levels a single-level EBP can be instrumental in effectively ameliorating symptoms. An awareness of the entity, its pathophysiology as well as clinical features, and a multidisciplinary diagnostic and therapeutic approach go a long way in optimally managing SIH cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mokri B. Spontaneous CSF leaks: Low CSF volume syndromes. Neurol Clin 2014;32:397-422.  Back to cited text no. 1
    
2.
Kranz PG, Luetmer PH, Diehn FE, Amrhein TJ, Tanpitukpongse TP, Gray L. Myelographic techniques for the detection of spinal CSF leaks in spontaneous intracranial hypotension. AJR Am J Roentgenol 2016;206:8-19.  Back to cited text no. 2
    
3.
Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 2006;295:2286-96.  Back to cited text no. 3
    
4.
Davidson B, Nassiri F, Mansouri A, Badhiwala JH, Witiw CD, Shamji MF, et al. Spontaneous intracranial hypotension: A review and introduction of an algorithm for management. World Neurosurg 2017;101:343-9.  Back to cited text no. 4
    
5.
Woolen S, Gemmete JJ, Pandey AS, Chaudhary N. Targeted epidural patch with n-butyl cyanoacrylate (n-BCA) through a single catheter access site for treatment of a cerebral spinal fluid leak causing spontaneous intracranial hypotension. J Neurointerv Surg 2016;8:e26.  Back to cited text no. 5
    
6.
Sencakova D, Mokri B, McClelland RL. The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology 2001;57:1921-3.  Back to cited text no. 6
    
7.
Cohen-Gadol AA, Mokri B, Piepgras DG, Meyer FB, Atkinson JL. Surgical anatomy of dural defects in spontaneous spinal cerebrospinal fluid leaks. Neurosurgery 2006;58:S-45.  Back to cited text no. 7
    
8.
Nesbitt C, Amukotuwa S, Chapman C, Batchelor P. Lumbar blood patching for proximal CSF leaks: Where does the blood go? BMJ Case Rep 2015;2015:bcr2014206933.  Back to cited text no. 8
    
9.
Wu JW, Hseu SS, Fuh JL, Lirng JF, Wang YF, Chen WT, et al. Factors predicting response to the first epidural blood patch in spontaneous intracranial hypotension. Brain 2017;140:344-52.  Back to cited text no. 9
    
10.
Ferrante E, Arpino I, Citterio A, Wetzl R, Savino A. Epidural blood patch in Trendelenburg position pre-medicated with acetazolamide to treat spontaneous intracranial hypotension. Eur J Neurol 2010;17:715-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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