Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension
- Medical Division, Cardinal Stefan Wyszynski University, Warsaw, Poland.
- Department of Neurosurgery, Brodno Masovian Hospital, Warsaw, Poland.
Mateusz Miroslaw Zabek, Faculty of Medicine, Cardinal Stefan Wyszynski University, Warsaw, Poland.
DOI:10.25259/SNI_360_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Mateusz Miroslaw Zabek1, Grzegorz Turek2. Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension. 20-May-2022;13:215
How to cite this URL: Mateusz Miroslaw Zabek1, Grzegorz Turek2. Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension. 20-May-2022;13:215. Available from: https://surgicalneurologyint.com/surgicalint-articles/11600/
Background: Spontaneous intracranial hypotension (SIH) is a rare disease characterized by a decrease in the volume and pressure of cerebrospinal fluid (CSF) resulting from its leakage through the dura mater. SIH is curable, but it can lead to serious clinical sequelae or even death if not treated properly.
Case Description: A 37-year-old female with headaches occurring in standing position and increasing especially during verticalization. Magnetic resonance imaging showed an image characteristic of SIH. Conservative treatment was applied in the form of bed rest. CT myelography scan located the site of CSF leakage. As the conservative treatment proved inefficient, it was decided to perform an epidural fistula sealing using the patient’s venous blood, administered under computed tomography guidance. The performed procedure completely resolved the patient’s complaints, allowing her to be discharged home.
Conclusion: Patients with suspected SIH should remain in the supine position until a definitive diagnosis is made. Sealing the meningeal fistula with venous blood under computed tomography guidance should be considered in case of conservative treatment failure.
Keywords: Computed tomography myelography, Dura mater fistula seal, Epidural blood patch under computed tomography guidance, Intracranial hypotension, Spontaneous intracranial hypotension
Spontaneous intracranial hypotension (SIH) is a disease characterized by a decrease in the amount and/or pressure of cerebrospinal fluid (CSF). The cause of the decrease in CSF is its leakage through the damaged dura. Typically, there are no trauma, surgery, or other causes explaining the history of existing dura mater injury in SIH.
Severe, debilitating headache that occurs or worsens during verticalization is the main symptom reported by the patients. The reclining position provides patients with relief. Associated complaints in this syndrome may include double vision, tinnitus, dizziness, neck stiffness, nausea, vomiting, auditory hypersensitivity, deafness, and vision loss.[
Magnetic resonance imaging (MRI) is a useful examination in the diagnostics of SIH, allowing to find changes such as cerebral hemispheres lowered below the tentorial notch, diffuse enhancement of the arachnoid mater, dilation of the dura mater sinuses, subdural exudates or hematomas, wedging of the cerebellar tonsils, enlargement and swelling of the pituitary gland, atrophy of the suprasellar and perimesencephalic cistern, thrombosis of the meningeal sinuses, and epidural congestion of the spinal canal.[
Most patients recover with the conservative treatment which is limited to bed rest, hydration, and analgesics.[
A 37-year-old female patient, with typical symptoms of SIH and no history of trauma, was admitted to the hospital. Brain MRI showed peri hemispheric, subdural fluid collections, up to 4 mm thick [
Headaches are a widespread and common cause of patients presenting to hospital emergency departments (0.5–4.5%).[
Bed rest is the first and primary recommendation for the treatment of SIH and it is usually effective. The same authors stated that a 2-week bed rest is sufficient time to control that disease, whereas other authors stated that conservative treatment alone could not be effective.[
In this study, we presented a new approach in the treatment of SIH in cases when conservative treatment turned out to be ineffective. It consists in epidural sealing of the dural fistula with a blood patch formed from the patient’s venous blood, injected directly to the intravertebral foramen under guidance of CT. This minimally invasive procedure is a modification of a standard epidural blood patch injection similar to epidural blockade, but under guidance of fluoroscopy. We think that in the cases of damage to the nerve root sheath on the level of intravertebral foramen, using our modification, we are able to provide the blood patch more accurately for a more effective sealing of the damaged dura. With regard to other authors, we fully agree that using the contrast agent allows to visualize the administration site.[
Improperly treated SIH is a potentially fatal disease. Conservative treatment includes bed rest and, in most cases, is effective and may reduce the rate of serious complications. If conservative treatment is ineffective, a blood patch inserted to epidural space may be another treatment choice. We proposed modification of standard blood patch procedure for cases with damaged nerve root sheath on the level of intervertebral foramen by performing a blood patch through intervertebral foramen under guidance of CT. The procedure turned out to be easy, safe, and effective in the treatment of SIH.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
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Conflicts of interest
There are no conflicts of interest.
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