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Abstract
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Background and Aims Spontaneous intracranial hypotension (SIH) is caused by a cerebrospinal fluid (CSF) leak without a specific history. The symptoms of SIH include orthostatic headache accompanied or not by symptoms such as neck pain, nausea, and vomiting. EBP is considered the treatment of choice when SIH does not respond to conservative treatment, and if symptoms do not improve, EBP can either be repeated or targeted to the leakage site. However there are some cases where repeated EBP does not show any improvement and are difficult to treat
Methods In the described case, symptoms persisted despite repetitive targeted EBP, and thus, we performed a simultaneous two-site EBP procedure. Briefly, with a needle placed simultaneously at C7/T1 and T11/12 levels, 8 ml and 12 ml of autologous blood were injected, respectively. Subsequently, symptoms improved without any side effects
Results After 2-site simultaneous EBP, the symptom improvement was well maintained, and the patient was discharged without any side effects. Brain CT images obtained a month after simultaneous targeted EBP confirmed complete absorption of the bilateral fluid collection
(a) Axial brain CT image show increased extent of bilateral subdural fluid collection(asterisk). (b) Sagittal T2-weighted MR whole spine image show extensive CSF leakage (blank arrow) below C3/4 level. (c)(d) Axial CT myelography image show CSF leakage at T9/10 and T12/L1 level (arrow)
Two-site simultaneous EBP. Needles were placed on the CT and TL junctions simultaneously. After both needles were placed, autologous blood was sequentially injected. (a) Two needles are placed at the same time at C7/T1 and T11/12 level. (b) First, 8ml of autologous blood was injected at the C7/T1 level. (c) After injection into the CT junction, 12ml of autologous blood was injected at the T11/12 level
Fluoroscopic image of the two-site simultaneous EBP. (a)(b) The first needle was placed at the C7/T1 level and 8ml of autologous blood was injected. (c)(d) The second needle was placed at the T11/T12 level and 12ml of autologous blood was injected
Conclusions 2-site simultaneous EBP can be an alternative treatment option in cases of spontaneous intracranial hypotension refractory to conservative therapy and traditional epidural blood patch.