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Clinical Neurology and Neurosurgery: E. Ferrante, F. Rubino, M. Mongelli, I. Arpino
Clinical Neurology and Neurosurgery: E. Ferrante, F. Rubino, M. Mongelli, I. Arpino
Headache Centre, Department of Neurological Science, Azienda Ospedaliera Niguarda Ca Granda, Milano, Italy
1st Unit of Anaesthesia and Intensive Care, Azienda Ospedaliera Niguarda Ca Granda, Milano, Italy
c
School of Specialization in Anaesthesiology and Intensive Care, University of MilanBicocca, Milan, Italy
b
a r t i c l e
i n f o
Article history:
Received 14 July 2014
Received in revised form 3 November 2015
Accepted 12 November 2015
Available online 26 November 2015
Keywords:
Headache
Subarachnoideal blood
Spontaneous intracranial hypotension
Epidural blood patch
a b s t r a c t
Objective: (1) To determine the frequency of subarachnoid blood spread following epidural blood patch
(EBP) in a cohort of subjects with spontaneous intracranial hypotension (SIH). (2) To describe the outcome
of these patients.
Patients and methods: In a cohort of 106 patients exhibiting SIH, spiral spinal CT scans were obtained
post-lumbar EBP and neuroradiological data was reviewed for evidence of subarachnoideal bleeding.
Results: Subarachnoideal blood spread was detected on spinal CT scans following EBP in 9 of 106 patients
with SIH. All patients exhibited a complete recovery and no neurological complications were observed.
Conclusions: A low incidence of subarachnoideal blood spread was observed following EBP given to treat
SIH. Instances of subarachnoideal blood spread were not associated with neurological complications or
altered efcacy of the EBP procedure.
2015 Elsevier B.V. All rights reserved.
1. Introduction
Spontaneous intracranial hypotension (SIH) is a syndrome
resultant from cerebrospinal uid (CSF) leakage and a subsequent
loss of CSF pressure. SIH produces a range of symptoms, but most
notably manifests with orthostatic headache (other symptoms
listed in Table 1) [1]. Lumbar autologous epidural blood patch (EBP)
is a procedure that has been primarily used for the treatment of
post-lumbar puncture headache [6], but in recent years EBP has
become a reliable treatment (and often the rst line treatment) for
orthostatic headache due to SIH [3].
Complications from EBP are quite rare but can include
pneumocephalus [7], spinal subdural haematoma or iatrogenic
subarachnoid haemorrhage [8,9], with secondary communicating
hydrocephalus and arachnoiditis [10]. To date, it is not known
whether neurological complications can arise from subrarachnoidal blood spread following EBP. Here we report the frequency
of subarachnoideal blood spread in a cohort of SIH patients and
44
Table 1
Symptoms associated to SIH other than headache [1].
Spinal pain
Nausea with or without emesis
Diplopia, horizontal and due to unilateral or bilateral 6th cranial nerve palsy
Diplopia due to 3rd or 4th cranial nerve palsy or both(much less common) [2]
Cochleovestibular manifestations
Photophobia, visual blurring
Upper limb numbness, paresthesias
Gait unsteadiness
Facial numbness, vague paresthesias, or weakness
Change in level of consciousness (from lethargy to coma) [3,4]
Personality change, memory decline, apathy, frontotemporal dementia-like
presentation
Movement disorders: choreiform, parkinsonism, torticollis, tremor
Bibrachialamyotrophy mimicking motor neuron disease [5]
Galactorrhea
Meniere-like syndrome
Upper limb radiculopathy
Trouble with bowel or bladder control
Fig. 1. Epidurography showing right needle placament (black arrow) and spread of
contrast medium in the epidural space (arrow heads).
45
Fig. 2. From left to right: (a) sagittal, (b) coronal and (c) axial spinal after EBP showing blood mixed with iopamidol in the subarachnoid space (white arrow) and air in the
epidural space (white star).
46
[5]
[6]
Acknowledgements
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