Recurrent Spontaneous Intracranial Hypotension (SIH) and the Durability of Repeat Epidural Blood Patch (EBP)

Ali Hazama; Fakhri Awawdeh; Alexander Braley; John Loree; Amar Swarnkar; Lawrence S Chin; Satish Krishnamurthy

doi:10.7759/cureus.41457

Recurrent Spontaneous Intracranial Hypotension (SIH) and the Durability of Repeat Epidural Blood Patch (EBP)

Cureus. 2023 Jul 6;15(7):e41457. doi: 10.7759/cureus.41457. eCollection 2023 Jul.

Authors

Ali Hazama¹, Fakhri Awawdeh², Alexander Braley¹, John Loree³, Amar Swarnkar⁴, Lawrence S Chin¹, Satish Krishnamurthy¹

Affiliations

¹ Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA.
² Neurological Surgery, Lake Erie College of Osteopathic Medicine, Elmira, USA.
³ General Surgery, Temple University Hospital, Philadelphia, USA.
⁴ Neuroradiology, The State University of New York Upstate Medical University, Syracuse, USA.

Abstract

Objective: Spontaneous intracranial hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) of the dural sac is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate the recent efficacy and outcomes of EBP for SIH at our institution.

Methods: Twenty-three patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018 at the same institution. All patients underwent brain MRI with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBP was placed one or two vertebral levels below areas of suspected leak, while the patient was positioned in the lateral decubitus position. Patients were seen in the outpatient setting within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 months following clinical relief of symptoms.

Results: 22/23 (95.7%) patients presented with complaints of orthostatic headache, and 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningeal enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had a subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, and 5/23 (21.7%) patients received further EBPs for persistent disease with all achieving relief after repeat EBP. 5/12 (41.7%) of patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient were 21.7 mL (median 20 mL, 7-40 mL) and 3.54 (median 1, 1-13) respectively. There was one complication from initial EBP (cervical dural tear requiring operative closure) treated with open surgical management successfully. In total, 18/23 (78.2%) patients are currently asymptomatic with regard to their SIH. The mean follow-up in this cohort was 2.6 years (median 1.8 years, 1.8 months-9.27 years).

Conclusions: EBP is a viable and effective option for the treatment of recurrent SIH caused by cerebrospinal fluid (CSF) leaks.

Keywords: blood patch; dural leak; orthostatic headache; spontaneous cerebrospinal fluid leak; spontaneous intracranial hypotension (sih); subdural hematoma.