gms | German Medical Science

Objective: Spontaneous intracranial hypotension is increasingly recognized as a cause for refractory headache. Symptoms are variable but oftentimes limit quality of life especially in younger patients. High resolution imaging using CT and MR-modality are of paramount importance for the localization of the suspected leak of cerebrospinal fluid in order to create a tailored therapeutic approach. Treatment can range from blood patch injection to invasive closure of the CSF leak. Success rates of conventional blood patch injection range from 29% to 60%. We present our series to investigate the safety and efficacy of targeted multisegmental epidural blood patch injection in the therapy of intracranial hypotension.

Methods: We reviewed cases of seventeen patients who were treated for refractory spontaneous intracranial hypotension at our institute between 2005 and 2019. Head and spine MRI as well as whole spine myelography with contrast were performed as standard diagnostic procedures. All patients underwent a surgical implantation of two epidural drains above and beneath the site of suspected CSF leak through a minimally invasive interlaminar microsurgical approach under general anaesthesia. Afterward, blood was injected at multiple levels under clinical surveillance in awake patients. This procedure was repeated in patients with persistent symptoms.

Results: Patients presented with orthostatic headache, vertigo, sensory deficits and hypoacusis (94%, 18%, 18%, 12% of the cases, respectively). Subdural effusions were present in 65% of the cases, either unilaterally (12%) or bilaterally (53%). An epidural CSF leakage was identified in all cases, 76% on MRI and 82% on myelography. The exact site of CSF leak could be defined in 71% of the cases (18% in cervical spine and 53% in thoracic spine). Drainage of subdural hematoma was necessary in 6% of the cases. Targeted injection of blood patch was performed with an average blood amount of 34 ml. Significant improvement of symptoms was reported in 94% of the cases. Two patients (12%) had recurrent symptoms and underwent a second blood patch injection. No therapy related complications were reported.

Conclusion: Targeted multisegmental blood patch injection is a safe technique that showed a higher success rate than other blood patch techniques for treatment of spontaneous intracranial hypotension. It is performed in a minimally invasive procedure that can be repeated if necessary with a very low risk profile.