After the patient failed IV caffeine, he was referred to the Pain Management Department for an epidural blood patch because of the positional nature of the headache and the low CSF pressure. The leaking CSF may favor clot formation at the site of dural tear. In addition, normal CSF pressures have been recorded in patients with typical clinical and radiological features. The CT myelogram was grossly abnormal with evidence of extensive subdural fluid collection in the midthoracic spine from T3 to T9 and a small amount of epidural contrast, suggesting this represented the primary site of CSF leak. See AFTER CARE. Likewise, patients with identifiable CSF leak and typical orthostatic headache with low CSF pressure may not exhibit pachymeningeal enhancement.
For the therapeutic response to be long lasting, sealing of the dural tear with a clot is required [26,27]. Spontaneous cerebrospinal fluid (CSF) leak is a rare clinical entity that may result in disabling headaches. This exacerbation was successfully treated with a lumbar epidural blood patch, but her original headache persisted. In a few patients, no orthostatic headache is perceived despite typical imaging features and low CSF pressures. If the initial non-targeted EBP is unsuccessful, a second, larger-volume EBP is sometimes considered, and some recommend a third lumbar or thoracic level EBP before proceeding with localization of the leak and directed EBPs. MRI of the thoracolumbar spine revealed epidural soft tissue with lobulated configuration extending from the T3 to the T8-T9 level with irregular hypointensity along the periphery, reflecting recent epidural blood injection. However, the positional headache can later evolve into a persistent chronic daily headache.
If a first blood patch does not fix the leak, do not become hopeless. Diagnostic findings include a low opening CSF pressure on spinal tap, CSF pleiocytosis, and increased protein concentration as well as characteristic findings on radiological studies and radioisotope cisternograms. Sign up to our mailing list and download a copy of our latest newsletter by clicking here. This can often repair the leak. On MRI, there was diffuse enhancement of the thickened dura, findings compatible with CSF leak (Figure 3). The tear or hole allows the CSF to leak out. Venous Fistula Surgery. Our comprehensive evaluation often identifies CSF leaks in people whose symptoms have not responded to conventional treatment. MRI scans can help determine the location and severity of a CSF leak.
Not only does an epidural blood patch result in rapid onset of relief, the abatement of symptoms is long lasting in the majority of cases of post dural puncture headache . He was admitted for intravenous hydration and underwent a lumbar epidural blood patch. Initial workup by his family physician with CT scan and MRI of the brain and cervical spine was unremarkable. Initially, her headache was achy, global, and nonthrobbing with a positional component. Associated symptoms included nausea and lightheadedness, but he had no focal motor sensory disturbances. In general, conservative treatments are usually tried first for leaks at either location. Pledget study: This simple test involves inserting pledgets (small cotton pads) into your nose. A connective tissue disorder or abnormality was identified in a substantial proportion of patients with CSF leaks . If the leak is caused by the sharp edge of a spinal disc rubbing against the dura, a surgeon can stop the friction and repair the leak by shaving off the sharp edge and wrapping the dura with collagen fiber. Some strategies for conservative management/treatment of a spinal CSF leak are: Bedrest in a horizontal/flat position for 24 to 72 hours. Bed rest (days to up to 2 weeks) Hydration (2 to 3 quarts) IV caffeine infusions