CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension

Abstract

Optimal diagnosis and management of spontaneous intracranial hypotension remains uncertain. CT-guided blood patching has been described but has not been evaluated in larger case series. We sought to evaluate the efficacy of CT-guided blood patching of observed or potential CSF leaks in spontaneous intracranial hypotension. Patients referred for evaluation of spontaneous intracranial hypotension were retrospectively reviewed. Inclusion criteria were findings of intracranial hypotension on pretreatment brain MR imaging, evaluation and treatment with CT-guided myelography and blood patching, and availability of posttreatment brain MR images. Eight patients met inclusion criteria. Imaging findings, treatment details, and clinical outcomes were assessed. Pretreatment imaging findings included dural enhancement, tonsillar ectopia, subdural collections, and syrinx. All findings resolved or significantly improved on posttreatment imaging. Presenting clinical symptoms included positional headache, neck/interscapular/shoulder pain, and tinnitus. Headaches and neck/interscapular/shoulder pain improved in all patients; tinnitus improved in 1 of 2 patients. CSF leak sites were directly visualized in 37% of patients and were targets for patching when seen. When no direct visualization of leaks was seen, irregular spinal nerve root diverticula were targeted as potential leak sites. The average number of blood patching sessions was 3 (range, 1-6) and the average number of individual sites patched per session was 5 (range, 1-10). Our results suggest that CT-guided blood patching targeting observed or potential leak sites can be effective in the treatment of intracranial hypotension. Prospective controlled studies are needed to confirm efficacy and compare outcomes with other treatment options.