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| 21KF-005 |
Subdural Hematoma after Spontaneous C1/2 Cerebrospinal Fluid Leak Treated with a Targeted Epidural Blood Patch
1 Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
2 Department of Anesthesiology and Pain Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
Introduction
Spontaneous intracranial hypotension (SIH) is a rarely presented clinical syndrome of low cerebrospinal fluid (CSF) pressure (less than 60 mmH2O) resulting from spontaneous CSF leak in patients without a previous history of dural puncture or trauma. Subdural hematoma (SDH), a serious complication of SIH, may lead to neurological deficits.
Case summary
A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache, nausea, and vomiting. Brain computed tomography (CT) imaging and brain magnetic resonance imaging (MRI) findings showed chronic SDH. The patient underwent burr hole trephination, but the symptom was aggravated. MR myelogram was highly suspicious for CSF leakage at C1/2 (Fig. 1A, B, C). Therefore, we performed a targeted cervical epidural blood patch (EBP) using an epidural catheter under fluoroscopic guidance at HD 17. The procedure was performed that a 18-gauge epidural needle was slowly inserted at the C6/7 interlaminar space using a right paramedian approach under fluoroscopic guidance. The needle was advanced into the epidural space using a loss of resistance technique. The epidural space was confirmed with visualization of the contrast agent using anteroposterior and lateral fluoroscopic views. (Fig. 2), Despite multiple attempts, we were unable to further advance the catheter to C1/2 level, the epidural catheter was directed in the cephalad direction to the C3/4 level in the right paramedian. We injected one mL of contrast media for confirming the spread of contrast dye at the C1/2 level (Fig. 2A, B). Then, 5 mL of autologous blood was injected via the epidural catheter.
At 5 days after EBP, a follow-up MR myelogram revealed a decreased interval size of the CSF collected (Fig. 1D, E, F). Although his symptoms improved, he still complained of headaches, so we repeated the targeted cervical EBP 6 days after the initial EBP and we confirmed that the catheter tip approached the correct C1/2 level (Fig. 2C, D). Subsequently, his headache had almost disappeared on the 8th day after repeated EBP, the patient discharged.
Conclusion
Targeted EBP via a cervical epidural catheter inserted from the lower cervical spine under fluoroscopic guidance was an effective method of treatment for SDH in a patient with SIH due to CSF leakage at the C1/2 level.
Spontaneous intracranial hypotension (SIH) is a rarely presented clinical syndrome of low cerebrospinal fluid (CSF) pressure (less than 60 mmH2O) resulting from spontaneous CSF leak in patients without a previous history of dural puncture or trauma. Subdural hematoma (SDH), a serious complication of SIH, may lead to neurological deficits.
Case summary
A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache, nausea, and vomiting. Brain computed tomography (CT) imaging and brain magnetic resonance imaging (MRI) findings showed chronic SDH. The patient underwent burr hole trephination, but the symptom was aggravated. MR myelogram was highly suspicious for CSF leakage at C1/2 (Fig. 1A, B, C). Therefore, we performed a targeted cervical epidural blood patch (EBP) using an epidural catheter under fluoroscopic guidance at HD 17. The procedure was performed that a 18-gauge epidural needle was slowly inserted at the C6/7 interlaminar space using a right paramedian approach under fluoroscopic guidance. The needle was advanced into the epidural space using a loss of resistance technique. The epidural space was confirmed with visualization of the contrast agent using anteroposterior and lateral fluoroscopic views. (Fig. 2), Despite multiple attempts, we were unable to further advance the catheter to C1/2 level, the epidural catheter was directed in the cephalad direction to the C3/4 level in the right paramedian. We injected one mL of contrast media for confirming the spread of contrast dye at the C1/2 level (Fig. 2A, B). Then, 5 mL of autologous blood was injected via the epidural catheter.
At 5 days after EBP, a follow-up MR myelogram revealed a decreased interval size of the CSF collected (Fig. 1D, E, F). Although his symptoms improved, he still complained of headaches, so we repeated the targeted cervical EBP 6 days after the initial EBP and we confirmed that the catheter tip approached the correct C1/2 level (Fig. 2C, D). Subsequently, his headache had almost disappeared on the 8th day after repeated EBP, the patient discharged.
Conclusion
Targeted EBP via a cervical epidural catheter inserted from the lower cervical spine under fluoroscopic guidance was an effective method of treatment for SDH in a patient with SIH due to CSF leakage at the C1/2 level.
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