Evaluation and treatment of spontaneous intracranial hypotension

Abstract

Background and purpose: Spontaneous intracranial hypotension (SIH) is a significant, treatable cause of postural headache, although the best diagnostic approach to diagnosing cerebrospinal fluid (CSF) leaks remains uncertain. The aim of this study is to evaluate the most common techniques used to diagnose leaks, the most frequent leak sites, and epidural patch treatment characteristics. Materials and methods: We retrospectively reviewed the electronic medical records and radiographic findings of 30 patients clinically treated for SIH at a single university hospital between January 2015 and December 2016. Clinical symptoms, imaging findings and epidural patch details including dates, injection location, and amount of blood/fibrin injected were recorded. Results: Of 30 SIH patients identified, 11/30 (37%) had a localized leak and 14/30 (47%) had a non-localized leak. The first modality to identify the leak was most commonly CT myelogram (17/25, 68%), followed by MRI spine (6/25, 24%) and MRI myelogram (2/25, 8%). The most frequent leak sites were C7–T1, C5–C6, and T10–T11 in decreasing order. All patients underwent CT-guided epidural patch, averaging 2.3 procedure sessions, 3.4 injection sites, and 7.8 mL of injectate per site. Conclusion: Spinal CSF leak remains a challenging diagnosis, with CT myelography most frequently confirming the diagnosis, supplemented by spine MRI and MRI myelography. Patients frequently require multiple injections at multiple sites, and physicians and patients should be aware of the possible need for repeat treatments. Given the most common sites of leak, empiric blood patch at the cervicothoracic or thoracolumbar junction should be considered if no definitive leak is identified. Keywords: Headache, Cerebrospinal fluid leak, Blood patch