Content area
Full text
Background
Spontaneous cerebrospinal fluid (CSF) leaks are not uncommon and are associated with intracranial hypotension and postural headaches. Although a number of therapeutic approaches exist, first-line treatment generally consists of epidural blood patching (EBP) in the lumbar area, even in the setting of more proximal CSF leaks. We report a case of a cervical fluid leak being successfully managed with lumbar blood patching with follow-up imaging confirming that the blood ascended proximally within the epidural space. This case supports a twofold hypothesis: that the therapeutic response from lumbar blood patching initially results from a tamponade effect leading to immediate symptom relief and subsequently blood products ascending and forming a localised clot. The negative pressure gradient that exists within the epidural space may be essential to the rostral flow of injected blood products and this gradient is possibly augmented in the setting of intracranial hypotension.
Case presentation
We present the case of a 41-year-old woman with a 12-month history of increasingly severe postural pressure headaches associated with neck stiffness. Her headaches significantly worsened on standing from recumberance and with prolonged standing, gaining relief on lying flat. The patient also had monthly attacks of severe headaches associated with 'blurred; vision, nausea and vomiting and episodes of intermittent syncope associated with the pain. Treatment for migraines over the preceding 12 months with sandimigran and simple analgesia was ineffective.
The patient had a history of two motor vehicle accidents; one at age 18 associated with a head injury requiring cognitive rehabilitation with good functional outcomes, and a second accident at age 23 also with full resolution.
Investigations
CT and MRI of the brain and spine at presentation demonstrated features of intracranial hypotension. These included pachymeningeal thickening and enhancement, intracranial venous engorgement and sagging of intracranial structures. MRI of the spine revealed epidural venous engorgement, consistent with hypotension, and an epidural CSF intensity fluid collection continuous over four spinal segments; the exact site of CSF leakage was not seen but presumed to be within the level of the fluid collection in the cervical spine ( figure 1 A, B).
Treatment
A 25 mL EBP was performed in the lumbar region with the patient in a sitting position, together with conservative measures including a period of strict bed rest for days...