An Epidural Blood Patch for Spontaneous Intracranial Hypotension - A Case Report

Abstract

Spontaneous Intracranial Hypotension (SIH) is a potentially serious, rare, pathophysiological entity of diverse origin. Orthostatic headache, low CSF pressure and diffuse meningeal enhancement on brain MRI are the major features. We report a 36 year old nun with an acute onset of severe headache over the vertex of the head becoming holo-cephalic, associated with neck pain, peaking in intensity in 15-on assuming the erect posture and relieved on assuming the recumbent position. Conventional treatment resulted in minimal improvement. MRI of the brain with gadolinium showed cerebellar tonsillar descent and diffuse meningeal enhancement. Lumbar puncture revealed an opening pressure of 60 mm of H2O and the CSF unremarkable on analysis. With the working diagnosis of SIH, she was posted for an epidural blood patch. After a pre-anaesthetic checkup and due consent, the patient was pre-medicated. In the operating room, the patient was positioned and draped in the left lateral position with a 15 degree trendelenburg tilt. At the L2-L3 intervertebral space, the primary anaesthesiologist identified the epidural space with an 18G Touhy needle adopting the loss of resistance to air technique. Simultaneously a 16G needle with extension was secured by the first assistant in the cephalic vein. Blood collected in 10 mL syringes was then introduced into the epidural space. After a volume of 26 mL, significant lower limb parasthesia and pain was complained of. The procedure was halted and the patient placed supine. She was discharged and noted to be symptom free at follow ups.