EPIDURAL BLOOD PATCH IN SPONTANEOUS INTRACRANIAL HYPOTENSION

Abstract

Background: Spontaneous Intracranial Hypotension (SIH) is a rare condition caused by a spinal cerebrospinal fluid (CSF) leak. It is usually described as an orthostatic headache, frequently associated with neck pain, nausea, vomiting, diplopia, blurred vision and distorted hearing. Initial treatment consists of bed rest, fluid supplementation, caffeine and analgesics. If conservative treatment fails, an epidural blood patch (EBP) therapy should be considered. Methods: A healthy 31-year-old female patient presented with a spontaneous occipital headache during the expulsive period of a miscarriage. Six days later, she was referred to Neurology due to worsening symptoms (orthostatic headache, vertigo and diplopia). CAT scan, lumbar puncture and carotid ecodoppler were normal. Magnetic Resonance Imaging (MRI) revealed an epidural CSF collection suggesting a CSF fistula. After 21 days of conservative treatment and no clinical improvement, she was referred to Anaesthesiology to perform a lumbar EBP. Hospital discharged occurred five days later with no symptoms. The follow-up MRI was normal. Discussion: Treatment of SIH aims to maintain CSF volume. The effect of EBP is twofold: an early effect related to volume replacement and a latent effect that results from sealing the leak. Symptomatic relief is usually obtained in few days but EBP may be repeated if symptoms recur. Complications such as transient paraesthesia, radicular pain, repeated inadvertent dural puncture and epidural infection are possible but rare. Conclusions: The high success rate and the low incidence of complications have established the EBP as the best available treatment of SIH refractory to conservative measures.