Lumbar epidural blood patch: effectiveness on orthostatic headache and MRI predictive factors in 101 consecutive patients affected by spontaneous intracranial hypotension

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Although epidural blood patch (EBP) is considered the gold-standard treatment for drug-resistant orthostatic headache in spontaneous intracranial hypotension (SIH), no clear evidence exists regarding the best administration method of this technique (blind vs target procedures). The aim of this study was to assess the long-term efficacy of blind lumbar EBP and predictors on preoperative MRI of good outcome.


Lumbar EBP was performed by injecting 10 ml of autologous venous blood, fibrin glue, and contrast medium in 101 consecutive patients affected by SIH and orthostatic headache. Visual analog scale (VAS) scores for headache were recorded preoperatively, at 48 hours and 6 months after the procedure, and by telephone interview in July 2017. Patients were defined as good responders if a VAS score reduction of at least 50% was achieved within 48 hours of the procedure and lasted for at least 6 months. Finally, common radiological SIH findings were correlated with clinical outcomes.


The median follow-up was 60 months (range 8–135 months); 140 lumbar EBPs were performed without complications. The baseline VAS score was 8.7 ± 1.3, while the mean VAS score after the first EBP procedure was 3.5 ± 2.2 (p < 0.001). The overall response rate at the 6-month follow-up was 68.3% (mean VAS score 2.5 ± 2.4, p < 0.001). Symptoms recurred in 32 patients (31.7%). These patients underwent a second procedure, with a response rate at the 6-month follow-up of 78.1%. Seven patients (6.9%) did not improve after a third procedure and remained symptomatic. The overall response rate at the last follow-up was 89.1% with a mean VAS score of 2.7 ± 2.3 (p < 0.001). The only MRI predictors of good outcome were location of the iter > 2 mm below the incisural line (p < 0.05) and a pontomesencephalic angle (PMA) < 40° (p < 0.05).


Lumbar EBP may be considered safe and effective in cases of drug-refractory SIH. The presence of a preprocedural PMA < 40° and location of the iter > 2 mm below the incisural line were the most significant predictors of good outcome. Randomized prospective clinical trials comparing lumbar with targeted EBP are warranted to validate these results.

ABBREVIATIONS EBP = epidural blood patch; IH = intracranial hypotension; PMA = pontomesencephalic angle; SIH = spontaneous IH; VAS = visual analog scale.

Article Information

Correspondence Vincenzo Levi: Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

INCLUDE WHEN CITING Published online February 8, 2019; DOI: 10.3171/2018.10.JNS181597.

V.L. and N.E.D.L. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Representation of the aspiration effect on the dural surface caused by the excessive negative vein outflow pressure. Movement of venous blood tends to obey a single law: the pressure gradient law. This pressure gradient may change at any time, influenced by different dynamic factors such as the diameter of the vessel, the position of the limb, the phase of cardiac and respiratory cycle, and body posture. At rest, for instance, during the middle phase of respiration, blood flow is at its greatest in the deep venous network. Blood is aspirated from smaller veins toward the deep venous network, and venous valves are opened. On the contrary, venous blood drainage decreases during a respiratory pause. The inferior vena cava system is much more affected by these dynamic modifications than the superior vena cava system. Indeed, atrial diastolic aspiration along with the strong muscle pump activity of the inferior limbs, which displaces a large amount of blood toward the heart during standing and walking, provokes a marked venous pressure decrease in the inferior vena cava system. Negative pressure within the inferior vena cava will then result in overdrainage of venous blood from the epidural spinal vein network acting as an aspiration force applied to the entire dural surface. This mechanism would be responsible for CSF “steal” through the dura itself or through provoked fistulas where the dura is particularly thin or fenestrated (such as in the radicular pockets). Following this theory, it can be argued that a rise in epidural pressure by injecting a viscous compound into the epidural space would balance the “aspiration” effect on the dural surface and minimize CSF steal. In other words, if the gradient between the intradural and epidural compartment is null, so will be the CSF passage between the 2 spaces. Copyright Nicola Ernesto Di Laurenzio. Published with permission. Figure is available in color online only.

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    Lateral intraoperative fluoroscopy. Homogeneous distribution of the compound injected is noticed along the lumbar and thoracic epidural space.

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    Midsagittal T1-weighted MR image showing quantitative alterations associated with SIH. Blue lines: Angle between the vein of Galen and straight sinus. Pink line: Distance between the opening of the sylvian aqueduct (i.e., the iter) and the incisural line (the green line extending from the anterior tuberculum sellae through the confluence of the great cerebral vein, inferior sagittal sinus, and straight sinus). Purple line: PMA. Yellow line: Chamberlain’s line, joining the back of the hard palate with the opisthion on a lateral view of the craniocervical junction. Red line: Downward displacement of the cerebellar tonsils. Figure is available in color online only.

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    Typical SIH brain MRI findings. A: After injection of gadolinium, an intense and diffuse pachymeningeal enhancement is observed along cerebral convexity bilaterally. B: Bilateral subdural collections of hemispheric fluid.

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    Response rates after the first, second, and third EBPs.



Bezov DLipton RBAshina S: Post-dural puncture headache: part I diagnosis, epidemiology, etiology, and pathophysiology. Headache 50:114411522010


Cho KIMoon HSJeon HJPark KKong DS: Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch. Neurology 76:113911442011


Clark MSDiehn FEVerdoorn JTLehman VTLiebo GBMorris JM: Prevalence of hyperdense paraspinal vein sign in patients with spontaneous intracranial hypotension without dural CSF leak on standard CT myelography. Diagn Interv Radiol 24:54592018


Crawford JS: Experiences with epidural blood patch. Anaesthesia 35:5135151980


Davidson BNassiri FMansouri ABadhiwala JHWitiw CDShamji MF: Spontaneous intracranial hypotension: a review and introduction of an algorithm for management. World Neurosurg 101:3433492017


Ducros ABiousse V: Headache arising from idiopathic changes in CSF pressure. Lancet Neurol 14:6556682015


Ferrante EArpino ICitterio AWetzl RSavino A: Epidural blood patch in Trendelenburg position pre-medicated with acetazolamide to treat spontaneous intracranial hypotension. Eur J Neurol 17:7157192010


Fishman RA: Cerebrospinal Fluid in Disease of the Nervous Systemed 2. Philadelphia: Saunders1992


Franzini AMessina GChiapparini LBussone G: Treatment of spontaneous intracranial hypotension: evolution of the therapeutic and diagnostic modalities. Neurol Sci 34 (Suppl 1):S151S1552013


Franzini AMessina GNazzi VMea ELeone MChiapparini L: Spontaneous intracranial hypotension syndrome: a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients. J Neurosurg 112:3003062010


Franzini AZekaj EMessina GMea EBroggi G: Intracranial spontaneous hypotension associated with CSF cervical leakage successfully treated by lumbar epidural blood patch. Acta Neurochir (Wien) 152:199719992010


Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders: 3rd edition (beta version). Cephalalgia 33:6298082013


Kranz PGAmrhein TJGray L: CSF venous fistulas in spontaneous intracranial hypotension: imaging characteristics on dynamic and CT myelography. AJR Am J Roentgenol 209:136013662017


Kranz PGMalinzak MDAmrhein TJGray L: Update on the diagnosis and treatment of spontaneous intracranial hypotension. Curr Pain Headache Rep 21:372017


Kumar NDiehn FECarr CMVerdoorn JTGarza ILuetmer PH: Spinal CSF venous fistula: a treatable etiology for CSF leaks in craniospinal hypovolemia. Neurology 86:231023122016


Lad SPLi GLin SCHenderson JM: Intracranial hypotension from intrathecal baclofen pump insertion. A case report and review of the literature. Stereotact Funct Neurosurg 86:75792008


Mea EChiapparini LSavoiardo MFranzini ABussone GLeone M: Clinical features and outcomes in spontaneous intracranial hypotension: a survey of 90 consecutive patients. Neurol Sci 30 (Suppl 1):S11S132009


Mokri B: Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache 53:103410532013


Pattichis AASlee M: CSF hypotension: a review of its manifestations, investigation and management. J Clin Neurosci 34:39432016


Rahman MBidari SSQuisling RGFriedman WA: Spontaneous intracranial hypotension: dilemmas in diagnosis. Neurosurgery 69:4142011


Rettenmaier LAPark BJHolland MTHamade YJGarg SRastogi R: Value of targeted epidural blood patch and management of subdural hematoma in spontaneous intracranial hypotension: case report and review of the literature. World Neurosurg 97:27382017


Richard SHumbertjean LMione GBraun MSchmitt EColnat-Coulbois S: Syringomyelia caused by traumatic intracranial hypotension: case report and literature review. World Neurosurg 91:674.e13674.e182016


Santangelo GSchmidt TGonzalez MWestesson PLSilberstein H: Novel technique of percutaneous fat graft for repair of persistent large pseudomeningocele. World Neurosurg 106:1055.e131055.e172017


Schaltenbrand G: Normal and pathological physiology of the cerebrospinal fluid circulation. Lancet 1:8058081953


Schievink WI: Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 295:228622962006


Schievink WIMoser FGMaya MM: CSF-venous fistula in spontaneous intracranial hypotension. Neurology 83:4724732014


Sencakova DMokri BMcClelland RL: The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology 57:192119232001


Shah LMMcLean LAHeilbrun MESalzman KL: Intracranial hypotension: improved MRI detection with diagnostic intracranial angles. AJR Am J Roentgenol 200:4004072013


Smith KA: Spontaneous intracranial hypotension: targeted or blind blood patch. J Clin Neurosci 25:10122016


Szeinfeld MIhmeidan IHMoser MMMachado RKlose KJSerafini AN: Epidural blood patch: evaluation of the volume and spread of blood injected into the epidural space. Anesthesiology 64:8208221986


Tu ACreedon KSahjpaul R: Iatrogenic cerebrospinal fluid leak and intracranial hypotension after gynecological surgery. J Neurosurg Spine 21:4504532014


Wu JWHseu SSFuh JLLirng JFWang YFChen WT: Factors predicting response to the first epidural blood patch in spontaneous intracranial hypotension. Brain 140:3443522017




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