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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OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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. vincenzo.levi@unimi.it.

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.

Headings

Figures

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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.

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