AB170. SOH23ABS_238. Epidural blood patch for spontaneous intracranial hypotension (case report)

Background: Spontaneous intracranial hypotension (SIH) is caused by spinal leakage of cerebrospinal fluid (CSF) and it is characterized by an orthostatic headache without a history of trauma or dural puncture. SIH may lead to serious complications such as subdural haematoma (SDH), may lead to neurological deficits and can even be life-threatening. Lumbar epidural blood patching (EBP) has been regarded as the mainstay of therapy for SIH, often providing instantaneous relief of symptoms in 90% of cases regardless of the site of the leak. There is no conclusive evidence regarding the specific time from the onset of symptoms after which the epidural blood patch should not be tried. This report presents a case of SIH that was successful with lumbar EBP after 6 weeks of symptom onset.

Methods: We present a case of a 39-year-old male patient, who presented to emergency department (ED) with an orthostatic headache for almost 6 weeks and the onset was 2 weeks after he slipped over stairs without any obvious trauma of fracture. It was the typical orthostatic headache and associated with dizziness. The patient was admitted to the ward where conservative management was commenced. Scanning of the brain was not impressive but magnetic resonance imaging (MRI) spine showed hyperintensity which represent fluid in the posterior epidural space at T9 level. In addition to some fluid/oedema in the epidural space of the lumbar spine, the diagnosis was SIH. A referral from the neurology team to the pain team requesting an epidural blood patch as the conservative treatment is not successful. After a discussion with the patient, he was happy with an epidural blood patch trial. Under the complete aseptic technique, an epidural blood patch was injected at the L2,3 level. An autologous blood patch was collected from the right brachial vein and a total of 18 mL of autologous blood was injected into the epidural space.

Results: A few hours after the procedure the patient was discharged home. Post procedure follow up was done by phone for few days, he reported his symptoms definitely improved after epidural, but he did not return to his baseline or normal state because he was afraid to commences his usual daily activities. He was reassured him and advised to gradually increase his efforts.

Conclusions: Epidural blood patch could be worth trying for SIH even after 6 weeks of onset.

Keywords: Blood patch; epidural; headache; orthostatic; spontaneous intracranial hypotension (SIH)