Anesth Analg 2002;94:959-961
© 2002 International Anesthesia Research Society
NEUROSURGICAL ANESTHESIA
Blood Patch Therapy for Spontaneous Intracranial Hypotension: Safe Performance After Epidurography in an Unconscious Patient
Katsuyuki Terajima, MD*,
Yoshiyuki Oi, MD*,
Akira Ogura, MD*,
Naoyuki Sakai, MD
,
Mao Takei, MD,
Tomonori Tamaki, MD, and
Ryo Ogawa, MD, PhD*
*Department of Anesthesiology, Department of Neurosurgery, Nippon Medical School, Tokyo, Japan
Address correspondence and reprint requests to Katsuyuki Terajima, MD, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan. Address e-mail to YIB01174{at}nifty.ne.jp
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Abstract
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IMPLICATIONS: Epidurography was useful for identifying the epidural space and determining the likely spread of an epidural blood patch in an unconscious patient with spontaneous intracranial hypotension.
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Introduction
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Spontaneous intracranial hypotension (SIH) was originally described by Schaltenbrand in 1938 (1) and is a syndrome featuring low cerebrospinal fluid (CSF) pressure resulting from CSF leakage without any history of dural puncture, surgery, or penetrating trauma.
Most SIH patients present with a mild postural headache, which spontaneously resolves within a few days. However, some patients may have severe symptoms, including progressive postural headache, nausea, vomiting, dizziness, meningismus, and cranial nerve palsies (2). The most important complications of intracranial hypotension are bilateral subdural hematoma or hygroma and herniation of the cerebellar tonsils (3), which are believed to occur secondary to loss of buoyancy and resultant settling of the brain toward the skull base.
SIH is treated by bed rest with fluid supplementation, analgesic agents, and caffeine (3). If postural headache persists or neurologic symptoms occur, epidural blood patch (EBP) therapy is selected.
In this communication, we report that epidurography was helpful to safely perform an upper thoracic blood patch procedure in an unconscious patient with SIH and acute subdural hematoma.
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Case Report
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A healthy 48-yr-old woman presented with positional headache. She had been treated with analgesics for 1 wk, but her symptoms persisted. After she suffered loss of consciousness, she was admitted to our hospital by ambulance, and the trachea was intubated to secure the airway.
Computed tomography (CT) on admission showed bilateral subdural hemorrhages and lumbar puncture revealed a low CSF pressure of 2 cm H2O. Routine laboratory tests were normal. Magnetic resonance imaging (MRI) showed diffuse dural enhancement and downward herniation of the cerebral structures on a midsagittal image. Spinal MRI showed a fluid collection in the ventral epidural space at the cervicothoracic junction. SIH was strongly suspected to have caused bilateral subdural hematomas.
Evacuation of the hematomas was performed and an intracranial pressure monitor was placed, but the patient did not regain consciousness and remained intubated. On the third postoperative day, EBP was performed at Th3–4, near the cervicothoracic junction, where the dural tear was located according to the results of spinal MRI. A 17-gauge Tuohy needle (Epidural Catheterization Set®, Arrow International Inc., Reading, PA) was inserted and the epidural space was detected by the loss of resistance to saline at first challenge. When the stylet was removed, fluid seeped out very slowly. A 19-gauge epidural catheter (FlexTip Plus®, Arrow Int., Inc., Bernville Road Reading, PA, USA) was then inserted through the needle. Epidurography was performed with 5 mL of iotrolan (Isovist®, 240 mg/mL, Schering Inc., Berlin, Germany) being injected via the catheter (Fig. 1). Iotrolan is safe for subarachnoid injection (4). This procedure successfully confirmed that the catheter tip was in the epidural space.
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Figure 1. Radiographic film showing the contrast medium in the epidural space. Before injection of autologous blood, a total volume of 5 mL of iotrolan was injected through the catheter.
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Autologous blood 15 mL was injected with small dose of iotrolan. A CT scan, performed after the EBP procedure, revealed spread of the blood within the epidural space from C1 to L2 (Fig. 2). Intracranial pressure increased to 8 cm H2O after the EBP. The patient regained consciousness and the trachea was extubated on the day after EBP treatment. The patient returned to a normal neurologic status with no pain and no paralysis. MRI 2 wk later demonstrated restoration of the midline cerebral structures to their normal position. The patient has remained asymptomatic for 11 mo after EBP therapy.
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Figure 2. Computed tomographic epidurography at the level of C6 (A) and L1 (B) after the epidural blood patch. Fifteen mL of autologous blood with small dose of iotrolan was injected.
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Discussion
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When an EBP is applied, it is important to confirm that the blood is injected into the epidural space. Injection into the paraspinal muscles may be insufficient to correct the underlying CSF leak, resulting in the need for additional intervention to provide sustained relief of symptoms (5). Intrathecal blood injection may cause arachnoiditis or hydrocephalus. After epidurography was performed to identify the epidural space and the site of blood injection, the upper thoracic EBP was placed through the same catheter so that injection of blood into the subarachnoid space could be avoided.
Some investigators have suggested that the ventral cervicothoracic junction and the thoracic spine appear to be the most common locations for occult tears and subsequent CSF leakage (3). A lumbar epidural autologous blood patch is usually placed in SIH patients because the lumbar EBP is effective in 90% of cases (6). If the first lumbar blood patch is ineffective, a second blood patch is applied in the thoracic region (2,7). In consideration of the above points, the placement of an EBP near the leak might be more effective. However, thoracic (or cervical) EBP has a higher risk than lumbar EBP.
When blood is injected, there is temporary displacement of the nerve roots (8), which causes the radicular pain that occasionally accompanies injection of blood. These symptoms depend on the anatomy of the patient and the volume of blood injected. On the other hand, smaller volumes of <10 mL are associated with a more frequent initial failure rate or recurrence of postdural puncture headache after initial apparent success (9). Fifteen milliliters was recommended as the optimal volume of blood for use in performing autologous EBP therapy in the lumbar region, because this volume appears to spread bidirectionally (on average, six segments in the cephalad direction and three caudally (10). So we chose the same volume in this patient. After the EBP procedure, CT was helpful in confirming the range of spread.
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Conclusion
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Epidurography was useful to identify the epidural space in this patient who suffered from SIH with loss of consciousness. Blood patch was placed through the same catheter used for epidurography, this could avoid injection of blood into the subarachnoid space.
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References
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Wenzel-Hora BI. Iotrolan: the first dimeric non-ionic contrast medium for the subarachnoid space. Acta Radiol Suppl 1986; 369: 545–8.[Medline]
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Accepted for publication November 16, 2001.
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Abstract
Introduction
