Spontaneous intracranial hypotension: a recent indication for epidural blood patch

Abstract

Editor—We report the efficacy of a single lumbar blood patch, in spontaneous intracranial hypotension (SIH). SIH is characterized by intense headache leading to neurological referral. Diagnosis is mainly clinical, but magnetic resonance imaging (MRI) shows specific features. If the usual therapy fails, treatment with an epidural blood patch can be effective. Three female patients presented to our hospital with spontaneous, severe headache. The first patient, aged 38, had bilateral frontal headaches for 24 h, with positional features (decrease after 15 min of resting and increase in upright position). Lumbar puncture and MRI showed no unusual features. Pain was severe and did not respond to usual therapeutics. After discussion with the neurologists, an epidural blood patch was performed 3 days later by the anaesthetist in the operating room. After insertion of a 19 G Tuohy needle (Vygon, Ecouen, France) at the lumbar level, 16 ml of autologous blood were injected. The headache disappeared within an hour, and the patient was able to leave hospital the next day. The second patient, aged 28, described vertigo and photophobia, with major frontal headaches and inability to sit or stand up for 6 days. Lumbar puncture and brain-CT were normal, brain MRI showed a moderate diffuse pachymeningeal enhancement. An epidural blood patch was performed on the third day, by the anaesthesiologist, and 12 ml of autologous blood were injected. The headache disappeared within a few hours and the patient was discharged from hospital 3 days later. The third patient, aged 42, described occipital headaches over a period of 3 months with postural features, resistant to usual medical treatment, other than corticosteroids. Brain MRI showed pachymeningeal enhancement, bilateral subdural collection, and downward displacement of the cerebellar tonsil. Blood patch was performed a week later. Headaches disappeared within 48 h. The patient left hospital 3 days later. These three cases occurred within a 2-month period. SIH, is becoming better recognized as recent clinical reports in international anaesthetic literature show.1Rozec B Guillon B Desal H Blanloeil Y Value of epidural blood-patches for the treatment of spontaneous intracranial hypotension.Ann Fr Anesth Reanim. 2004; 23: 1144-1148Crossref PubMed Scopus (12) Google Scholar, 2Rozec B Guillon B Desal H Blanloeil Y Early blood-patch for spontaneous intracranial hypotension.Can J Anaesth. 2004; 51: 944-945Crossref PubMed Scopus (6) Google Scholar, 3Cousins MJ Brazier D Cook R Intracranial hypotension caused by cervical cerebrospinal fluid leak: treatment with epidural blood patch.Anesth Analg. 2004; 98: 1794-1797Crossref PubMed Scopus (47) Google Scholar SIH occurs mainly in young adult females. The mechanism the most likely involved is a leak of cerebrospinal fluid.4Beroir S Bousser M-G Spontaneous cerebrospinal fluid hypotension.EMC Neurologie. 2005; 1: 357-365Crossref Scopus (4) Google Scholar Diagnosis is by clinical features similar to those of our three case reports; orthostatic headaches relieved within a few minutes by lying down; bilateral, diffuse in most cases or occipital headaches; other features such as nausea and vomiting, vertigo, hearing disturbances, blurred sight. The most characteristic feature on MRI is the epidural and meningeal enhancement. Radiographic abnormalities can also be more important, including, as in the third case report, bilateral subdural fluid collections and downward displacement of cerebral structures. The lack of imaging features in the first case report is probably because of the very short time delay between the beginning of the headaches and MRI, and the major changes in the third case can be explained by the long delay for diagnosis. Lumbar puncture shows low cerebrospinal fluid pressure, with no specific abnormalities but is not recommended because of the risk of increasing the hypotension.4Beroir S Bousser M-G Spontaneous cerebrospinal fluid hypotension.EMC Neurologie. 2005; 1: 357-365Crossref Scopus (4) Google Scholar No evidence base exists, but treatments such as extended bed-rest, hydration, corticotherapy, caffeine and raising abdominal pressure have been described.4Beroir S Bousser M-G Spontaneous cerebrospinal fluid hypotension.EMC Neurologie. 2005; 1: 357-365Crossref Scopus (4) Google Scholar If these are ineffective, lumbar epidural blood patch, particularly if done early, appears to be effective.