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Lin PT, Wang YF, Hseu SS, Fuh JL, Lirng JF, Wu JW, Chen ST, Chen SP, Chen WT, Wang SJ. The SIH-EBP Score: A grading scale to predict the response to the first epidural blood patch in spontaneous intracranial hypotension. Cephalalgia 2023; 43:3331024221147488. [PMID: 36786320 DOI: 10.1177/03331024221147488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND To develop and validate an easy-to-use scoring system to predict the response to the first epidural blood patching in patients with spontaneous intracranial hypotension. METHODS This study recruited consecutive patients with spontaneous intracranial hypotension receiving epidural blood patching in a tertiary medical center, which were chronologically divided into a derivation cohort and a validation cohort. In the derivation cohort, factors associated with the first epidural blood patching response were identified by using multivariable logistic regression modeling. A scoring system was developed, and the cutoff score was determined by using the receiver operating characteristic curve. The findings were verified in an independent validation cohort. RESULTS The study involved 280 patients in the derivation cohort and 78 patients in the validation cohort. The spontaneous intracranial hypotension-epidural blood patching score (range 0-5) included two clinical variables (sex and age) and two radiological variables (midbrain-pons angle and anterior epidural cerebrospinal fluid collections). A score of ≥3 was predictive of the first epidural blood patching response, which was consistent in the validation cohort. Overall, patients who scored ≥3 were more likely to respond to the first epidural blood patching (odds ratio = 10.3). CONCLUSION For patients with spontaneous intracranial hypotension-epidural blood patching score ≥3, it is prudent to attempt at least one targeted epidural blood patching before considering more invasive interventions.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Shya Hseu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Anaesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Ting Chen
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Ministry of Health and Welfare Keelung Hospital, Keelung, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Predictors Associated with Outcomes of Epidural Blood Patch in Patients with Spontaneous Intracranial Hypotension. J Clin Med 2021; 10:jcm10050922. [PMID: 33670838 PMCID: PMC7957726 DOI: 10.3390/jcm10050922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
An autologous epidural blood patch (EBP) is a mainstay of treatment in patients with spontaneous intracranial hypotension (SIH). EBP, however, is less effective for SIH than post-dural puncture headaches. Therefore, patients with SIH frequently require an additional EBP. The aim of this study was to identify factors associated with poor response to EBP. This single-center retrospective observational study used the institutional registry records of 321 patients who underwent EBP between September 2001 and March 2016. Patients were divided into two groups, a poor responder group, consisting of patients who underwent EBP at least three times or more, and a good responder group of patients who experienced sufficient symptom relief after two or fewer EBP. The demographic characteristics, clinical features, radiologic findings, procedural data, and laboratory data were analyzed. Univariate analysis showed that the neutrophil-to-lymphocyte ratio (NLR; p = 0.004) and platelet-to-lymphocyte ratio (p = 0.015) were significantly lower in poor than in good responders. Multivariate analysis found that NLR was the only independent factor associated with a poor response (odds ratio = 0.720; p = 0.008). These findings indicate that a low NLR was associated with three or more EBP administrations for the sufficient improvement of symptoms in patients with SIH.
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Kanno H, Yoshizumi T, Nakazato N, Shinonaga M. Predictors of the Response to an Epidural Blood Patch in Patients with Spinal Leakage of Cerebrospinal Fluid. J Clin Neurol 2020; 16:1-8. [PMID: 31942752 PMCID: PMC6974819 DOI: 10.3988/jcn.2020.16.1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/21/2022] Open
Abstract
Background and Purpose An epidural blood patch (EBP) is a highly effective therapy for spinal cerebrospinal fluid (CSF) leakage. However, the factors predicting the response to an EBP have not been fully elucidated. The aim of this study was to elucidate factors predicting the response to an EBP. Methods We retrospectively examined the relationship between the response to an EBP and clinical variables of 118 patients with spinal CSF leakage, such as patient age, sex, etiology, interval from the onset to EBP application, CSF opening pressure (OP), radioisotope (RI) cisternography findings, rate of RI remaining in the CSF space, computed tomography (CT) myelography findings, magnetic resonance imaging (MRI) findings, and subjective symptoms (headache, vertigo/dizziness, visual disturbance, nausea, numbness, nuchal pain, back pain/lumbago, fatigability, photophobia, and memory disturbance). The correlations between these variables and the responses to EBPs were analyzed statistically. Results A positive response to an EBP was significantly (p<0.05) correlated with the following variables: <1.5 years from the onset to EBP application, age <40 years, CSF OP <7 cm H2O, epidural CSF leakage in RI cisternography, epidural CSF collection in MRI, <20% RI remaining after 24 hours, orthostatic headache, nausea, nuchal pain, and photophobia. The other variables did not show significant correlations with the responses to EBPs. Conclusions It might be prudent to take the following variables into account when applying an EBP to treat spinal CSF leakage: the interval from the onset to EBP application, age, CSF OP, epidural CSF leakage in RI, epidural CSF collection in MRI, rate of remaining RI, orthostatic headache, nuchal pain, photophobia, and nausea.
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Affiliation(s)
- Hiroshi Kanno
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan.
| | - Tetsuya Yoshizumi
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan
| | - Naomi Nakazato
- Department of Pharmacology, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan
| | - Masamichi Shinonaga
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan.
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Abstract
PURPOSE OF REVIEW Spontaneous intracranial hypotension (SIH) is an underdiagnosed phenomenon predominantly presenting with low cerebrospinal fluid (CSF) pressure and postural headache in setting of CSF leak. The goal of this paper is to provide updates on the pathology, diagnosis, and management of SIH. The utility of multiple imaging modalities and the use of epidural blood patches and fibrin glue polymers are explored. RECENT FINDINGS In regard to diagnosis, new non-invasive modalities in detection of SIH including transorbital ultrasound and serum biomarkers are found. In addition, increased efficacy of large volume and repeated placement of multiple epidural blood patches (EBP) are seen. In addition, the management of refractory SIH using fibrin glue polymers has proved efficacious in recent case series. While the diagnosis may be challenging for clinicians, future research in SIH is leading to more rapid detection methods. Future studies may target optimal use of EBP in comparison to fibrin glue polymers, in addition to new developments in increased understanding of SIH physiology and phenotype.
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Li C, Raza HK, Chansysouphanthong T, Zu J, Cui G. A clinical analysis on 40 cases of spontaneous intracranial hypotension syndrome. Somatosens Mot Res 2019; 36:24-30. [PMID: 30870079 DOI: 10.1080/08990220.2019.1566122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate clinical and imaging features of 40 patients with spontaneous intracranial hypotension (SIH). METHODS 40 cases of spontaneous intracranial hypotension (SIH) diagnosed in our hospital from June 2013 to September 2017 were collected and retrospectively analyzed. RESULTS In our study, the male to female ratio was 2:3. The average age of onset was 43.0 ± 15.0 years. There were 12 (30.0%) patients with clear incentives, mostly catching cold. The average length of hospital stay was 11.2 ± 6.3 days. All the patients showed orthostatic headaches, 62.5% patients with nausea or vomiting, 40.0% patients with neck stiffness, 17.5% patients with dizziness and vertigo, 10.0% patients with numbness and weakness of limbs, 5% patients with neck discomfort, and 2.5% patients with visual symptoms (visual impairment, photophobia, diplopia). 24 patients underwent CT scans which showed no abnormalities in 20 cases (83.3%), subdural fluid accumulation in 3 cases (12.5%), and subdural haematoma in 1 case (2.5%). Cranial contrast-enhanced MR scans showed diffuse pachymeningeal enhancement (95.83%, 23/24), signs of pituitary hyperaemia in 5 cases (20.8%), subdural fluid accumulation and subdural hematoma in 4 cases (16.7%), sagging of the brain in 3 cases (12.5%), and engorgement of venous structures in 1 case (4.1%). Six patients underwent plain and contrast-enhanced spinal MR scans which showed varying degrees of dural thickening and enhanced performance in all the patients. 92.5% (37/40) of patients had cerebrospinal fluid pressure <60 mmH2O on lumbar puncture. 97.5% of patients underwent conservative treatment with drugs and had a good outcome. CONCLUSION Orthostatic headache and cranial MRI diffuse pachymeningeal enhancement are characteristic features of SIH. Cranial contrast-enhanced MR scan is recognized as the first and non-invasive investigation in the diagnosis of SIH. Most patients had cerebrospinal fluid pressure <60 mmH2O. The vast majority of patients improved with fluid replacement.
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Affiliation(s)
- Cun Li
- a Postgraduate College Xuzhou Medical University , Xuzhou , China
| | - Hafiz Khuram Raza
- b School of International Education , Xuzhou Medical University , Xuzhou , China.,c Department of Neurology , the Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | | | - Jie Zu
- c Department of Neurology , the Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Guiyun Cui
- c Department of Neurology , the Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
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Qureshi AI, Kherani D, Waqas MA, Qureshi MH, Raja FM, Wallery SS. Effect of epidural blood injection on upright posture intolerance in patients with headaches due to intracranial hypotension: A prospective study. Brain Behav 2018; 8:e01026. [PMID: 29920982 PMCID: PMC6043705 DOI: 10.1002/brb3.1026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/09/2018] [Accepted: 05/12/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND We performed a prospective study to quantify changes in various aspects of upright posture intolerance in patients with intracranial hypotension. METHODS Six patients were provided a standard questionnaire before, immediately after epidural blood patch injection and at follow-up visit within 1 month after epidural blood injection inquiring: (a) How long can they stand straight without any support? (b) Do they feel any sense of sickness when they sit or lie down after standing? (c) How long do they have to wait before they are comfortable standing again after they have stood straight? (d) How effectively and fast can they get up from sitting or lying position to stand straight? and (e) Rate their activities in upright posture without support on a standard vertical visual analogue scale between 100 (can do everything) and 0 (cannot do anything). RESULTS All patients responded that they could not stand straight for ≥30 min (four responding <5 min) on pretreatment evaluation. All patients reported improvement in this measure immediately postprocedure with two reporting ≥30 min. At follow-up, three patients reported further improvement and one patient reported worsening in this measure. The magnitude of improvement ranged from 10 to 80 points increase immediately postprocedure in their ability to perform activities, while they are standing without any support on visual analogue scale. At follow-up, four patient reported additional improvement in their ability to perform activities, while they are standing without any support (ranged from 10 to 20 points increase compared with immediately postprocedure rating). CONCLUSIONS We present semiquantitative data on various aspects of upright posture intolerance in patients with intracranial hypotension before and after epidural blood injection.
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Affiliation(s)
- Adnan I. Qureshi
- Zeenat Qureshi Stroke InstituteSt. CloudMinnesota
- University of Illinois and MercyhealthRockfordIllinois
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