Epidural Blood Patching in Spontaneous Intracranial Hypotension-Do we Really Seal the Leak?

Spontaneous intracranial hypotension - a spinal disease

Spontaneous intracranial hypotension (SIH) remains an underdiagnosed condition despite increasing awareness due to recent scientific advances. Diagnosis can be delayed by the broad clinical presentation and imaging pitfalls. This results in a high degree of physical impairment for patients, including social and psychological sequelae as well as long-term damage in the case of delayed diagnosis and treatment.The study is based on a selective literature search on PubMed including articles from 1990 to 2023 and the authors' clinical experience from working in a CSF center.SIH mostly affects middle-aged women, with the primary symptom being position-dependent orthostatic headache. In addition, there is a broad spectrum of possible symptoms that can overlap with other clinical conditions and therefore complicate the diagnosis. The causative spinal CSF loss can be divided into three main types: ventral (type 1) or lateral (type 2) dural leak and CSF-venous fistula (type 3). The diagnosis can be made using a two-stage workup. As a first step, noninvasive MRI of the head and spine provides indicators of the presence of SIH. The second step using focused myelography can identify the exact location of the cerebrospinal fluid leak and enable targeted therapy (surgical or interventional). Intrathecal pressure measurement or intrathecal injection of gadolinium is no longer necessary for primary diagnosis. Serious complications in the course of the disease can include space-occupying subdural hematomas, superficial siderosis, and symptoms of brain sagging, which can lead to misinterpretations. Treatment consists of closing the dural leak or the cerebrospinal fluid fistula. Despite successful treatment, a relapse can occur, which highlights the importance of follow-up MRI examinations and emphasizes the chronic nature of the disease. This paper provides an overview of the diagnostic workup of patients with suspected SIH and new developments in imaging and therapy. · SIH is an underdiagnosed condition with a wide range of possible symptoms.. · The first diagnostic step using MRI provides indications of the presence of SIH.. · The second diagnostic step using (dynamic) myelography can identify the CSF leak.. · Collaboration with a CSF center is advisable for further diagnosis and treatment.. · Prompt detection and treatment of SIH improves the outcome.. · Zander C, Wolf K, El Rahal A et al. Spontaneous intracranial hypotension - a spinal disease. Fortschr Röntgenstr 2024; DOI 10.1055/a-2318-8994.

Health-related quality of life, work ability and disability among individuals with persistent post-dural puncture headache

BACKGROUND AND OBJECTIVES

Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects.

METHODS

We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21).

RESULTS

A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%.

CONCLUSION

This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

Safety and efficacy of transvenous embolization of cerebrospinal fluid-venous fistula in patients with spontaneous intracranial hypotension

BACKGROUND

Transvenous embolization is a recent treatment strategy for cerebrospinal fluid-venous fistulas (CSFVF), which are associated with spontaneous intracranial hypotension (SIH).

METHODS

Participants were selected from a prospective database on patients with CSFVF that received transvenous Onyx embolization. All patients underwent a brain magnetic resonance imaging (MRI) before and after embolization with MRI follow-up performed at least 3 months after treatment. Clinical and MRI results after treatment were described.

RESULTS

Twenty-one consecutive patients (median age 63 years, IQR = 58-71; females: 15/21 = 71.5%) with 30 CSFVF were included. Most lesions were situated between T9 and L1 (19/30 = 63%), 70% were right-sided, and 38% of the patients had multiples fistulas. Embolization was successful in all cases. The mean MRI SIH score before and after treatment was 6 (±2.5) and 1.4 (±1.6), respectively (p < 0.0001). Twenty patients (90%) experienced improvement of their initial condition, of which 67% reported complete clinical recovery. The mean HIT-6 score decreased from 67 (±15) to 38 (±9) (p < 0.0001), the mean amount of monthly headache days from 23.5 (±10) and 3.2 (±6.6) (p < 0.0001), the visual assessment scale (VAS) for headache severity from 8 (±1.9) to 1.2 (±2) (p < 0.0001), and the mean VAS for perception quality of life improved from 2.6 (±2.5) to 8.6 (±1.8) (p < 0.0001). There were no major complications. The suspected rebound headache rate after treatment was 33%.

CONCLUSION

Transvenous embolization of CSFVF allowed high rates of clinical improvement with no morbidity related to the treatment.

Percutaneous Treatment and Post-treatment Management of CSF Leaks and CSF-Venous Fistulas in Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is a treatable cause of orthostatic headaches secondary to pathologic loss of cerebrospinal fluid (CSF) from the subarachnoid space. SIH has several known pathologic causes including dural tears from disc osteophytes, leaks emanating from nerve root sleeve diverticula, and CSF-venous fistulas (CVFs). Depending on the type of leak, surgical repair or endovascular techniques may be options for definite treatment. However, epidural blood patching (EBP) remains first-line therapy for many patients due to its long track record, broad availability, and relatively lower risk profile. This review focuses on indications and techniques for the percutaneous treatment of SIH and provides an overview of post-procedural management of these patients.

A technique to localize posteriorly located spinal dural leaks associated with spontaneous intracranial hypotension: Dorsal-decubitus dynamic CT myelography

BACKGROUND

Precise localization and understanding of the origin of cerebrospinal fluid (CSF) leak is crucial to allow targeted treatment. We report the technical feasibility and utility of dorsal-decubitus dynamic computed tomography (DDDCT) myelography to localize posteriorly located dural defects in patients with suspicion of posterolateral dural tears.

METHODS

This study reports a series of four consecutive patients with posteriorly located SLEC and suspicion of posterolateral CSF leak who received DDDCT to localize the site of the leak. Patients were collected between October 2022 and October 2023. The technique of DDDCT and its efficacy to detect the site of CSF leak are reported.

RESULTS

In all four patients (three females, one male, mean age 39 years), DDDCT myelography was technically successful and precisely demonstrated the site of the CSF leak. In one patient with both anterior and posterior SLEC, DDDCT allowed to exclude the presence of a posteriorly located leak, while a subsequent ventral decubitus dynamic CT myelography localized the leak. Leak sites were all thoracic, except for one that was cervical. Information obtained from the DDDCT myelography was considered useful to target the treatment of the leak.

CONCLUSIONS

Based on our experience, DDDCT provided sufficient spatial and temporal resolution to pinpoint fast CSF leaks and it may be considered to localize posterolateral dural defects.

Spontaneous Intracranial Hypotension Due to CSF Leak at Multiple Spinal Levels—A Case Report and Literature Review

Introduction Spontaneous intracranial hypotension (SIH) is a misdiagnosed condition characterized by low cerebrospinal fluid (CSF) volume and an orthostatic headache that worsens with upright posture due to CSF leak at spinal dural defects. SIH due to CSF leak at multiple spinal levels is a rare condition, and only a few cases have been reported in the literature. Here, we report a case of SIH with a CSF leak at multiple spinal levels. The treatment options and efficacy of epidural blood patch (EBP) injection were discussed in this article.

Case Report A 36-year-old man presented with complaints of orthostatic headache for 2 months and a computed tomography myelogram demonstrated CSF leaks at multiple spinal levels through the dural defects at C5-C6, C6-C7, C7-T1, T1-T2 levels, and at L1, L2, L3, and L4 vertebral levels on the left side. He was managed with a targeted EBP injection and he improved symptomatically within 24 hours of the EBP injection.

Summary SIH is an entity that results from CSF leakage, often through spinal dural defects due to mechanical tear by osteophyte complex, disc prolapse, connective tissue disorders, CSF-venous fistula, and leaking meningeal diverticula. SIH can result from single or multiple dural leaks, but spinal leaks at multiple levels are uncommon. To the best of our knowledge, a total number of 163 cases have been reported in the literature so far. With good success rates, targeted EBP injection with autologous blood is an effective treatment option for both single-level and multiple-level spinal leaks.