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Journal of Society of Anesthesiologists of Nepal Case Report Benign JSAN 2016; 3 (1) JSAN 2015; 2 (1) JOURNAL OF SOCIETY OF ANESTHESIOLOGISTS OF NEPAL AN OFFICIAL PUBLICATION OF SAN Available online at www.jsan.org.np A PEER REVIEWED JOURNAL Journal of Society of Anesthesiologists of Nepal JSAN Volume 3, Number 1, March 2016 ISSN 2362-1281 Journal of Society of Anesthesiologists of Nepal 77 Case Report Benign intracranial hypotension caused by spontaneous cervical cerebrospinal fluid leak treated with cervical epidural blood patch: a case report Subhash Prasad Acharya, Bashu Dev Parajuli, Diptesh Aryal Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu, Nepal Abstract Spontaneous cervical cerebrospinal fluid leak is a rare entity and occurs because of tear in cervical dural layer. Management has been conservative in the past but here A R T I C L E I N F O we present this case that was managed successfully with cervical epidural blood Article History patch. A 36-year-old man presented to neurology outpatient clinic with headache Received 29.11.2015 in occipito-frontal region and dizziness for 15 days and managed with various Accepted 15.02.2016 modalities without benefit. The severity of headache increased in standing and Published 20.03.2016 sitting position but relieved in supine position. There was no history of trauma, fever, © Authors retain copyright photophobia, neck pain, tinnitus, weakness of other parts. Clinical examinations and grant the journal right of including neurological examinations were normal. So, magnetic resonance imaging first publication with the work of head and neck was obtained which showed dural leak in C3-C4 region. Adequate simultaneously licensed under hydration, caffeine and oral medications were prescribed without benefit and then Creative Commons Attribution after 5 days, Anesthesiology department was consulted and was planned for cervical License CC BY-NC-ND 4.0 that epidural blood patch. Under aseptic precaution in left lateral position with full neck allows others to share the work flexion, 18g Tuohy needle was inserted in c5-c6 epidural space by loss of resistance with an acknowledgment of the technique to air, and 15 ml of the autologous blood was injected. Then patient was work›s authorship and initial kept in supine position for 24 hours and neurological status was monitored frequently. publication in this journal. Over the next two days, patient became asymptomatic and was discharged. The patient was regularly followed up weekly for six weeks and then monthly for six months and had no reoccurrence of symptoms or other findings. Keywords: epidural blood patch; intracranial hypotension; spontaneous cerebrospinal fluid leak How to cite this article: Acharya SP, Parajuli BD, Aryal D. Benign intracranial hypotension caused by spontaneous cervical cerebrospinal fluid leak - treatment with cervical epidural blood patch: a case report. Journal of Society of Anaesthesiologists of Nepal (JSAN) 2016;3:47-49. http://dx.doi.org/10.3126/jsan.v3i1.14654. Corresponding Author Subhash Prasad Acharya, MD, FACC, FCCP Associate Professor, Department of Anesthesia Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu, Nepal Email: [email protected] Journal of Society of Anesthesiologists of Nepal 47 JSAN 2016; 3 (1) Introduction Discussion Benign intracranial hypotension (BIH) is a rare condition, Benign intracranial hypotension is a syndrome of low caused by CSF leak because of tear in the Dura because of CSF pressure characterized by postural headaches in unknown reasons. The management has been conservative patients without any history of dural puncture, surgery with hydration and analgesics but epidural blood patch has or penetrating trauma.1,2 Originally described by been tried with good results.1,2 We presented this as a first Schaltenbrand in 1938,3 BIH is thought to occur from reported case of epidural blood patch for BIH from this occult CSF leak resulting in decreased CSF volume and country as very few clinicians are aware of the diagnosis consequently, in low CSF pressure.1,2 It occurs mainly in and the available treatment option. young adult females.4 The characteristic headache is similar to Post Dural Puncture Headache (PDPH) which is mainly Case Report in the occipitofrontal region but can be diffuse and worsen Thirty-six years old male presented with chief complain within 15 minutes of sitting or standing position and of headache and dizziness for 15 days, associated with improves within 15-30 minutes in recumbent position.1,5 multiple episode of vomiting. The headache was localised The pain may be exacerbated by laughing, coughing, in the occipitofrontal region. There was positional variation jugular venous compression and Valsalva manoeuvre. The of the headache, which was relieved in supine position other features include nausea and vomiting, stiff neck, and the severity increased in standing and sitting position. vertigo, tinnitus, photophobia and blurred sight.5 Lumbar However, there was no history of photophobia, neck pain, puncture is usually not recommended as it may aggravate fever, trauma, running nose, weakness of any part of the the intracranial hypotension, but it usually reveals a low body or alteration in vision and hearing ability. opening CSF pressure less than 60 mm H2O or sometimes the measurement of pressure may not be possible.1 On admission, his vitals were stable and neurologic CSF analysis may be normal or reveal increased protein, examination revealed no abnormalities. Patient was initially xanthochromia, or lymphocytic pleocytosis. In our patient, investigated in the line of meningitis. All haematology the neurology team was suspecting meningitis and thus and biochemistry investigation were within normal limit send CSF analysis, which revealed mildly elevated proteins but cerebrospinal fluid (CSF) analysis showed 6 cells, all and lymphocytes. As this was inconclusive, and ruled out lymphocytes with borderline elevated protein and was infectious cause, MRI was planned suspecting BIH as a considered inconclusive by neurology team. MRI of brain possibility. was then performed which also revealed to be normal. With suspicion of low intracranial pressure headache, MRI Intracranial MR imaging findings of BIH are diffuse, intense of whole spine was performed and a high intensity area in meningeal enhancement and downward displacement the epidural space in anterior aspect with dural leak at C3- of brain structures.1 Spinal MR imaging can show spinal C4 cervical level was suspected. extradural CSF collection but the exact site of CSF leak may not be seen.1 The intracranial scanning was normal in our Initially the headache was attempted to relieve by patient however, high signal intensity area in the epidural adequate hydration, rest and codeine-paracetamol space in anterior aspect with suspicion of dural leak at C3- analgesic combinations. He was observed for 5 days but C4 cervical level was seen. since his symptoms didn’t improve, he was planned for Cervical Epidural Blood Patch. After counselling and written In 2008, Schievink described three criteria for diagnosing consent about the procedure and the possible outcomes, BIH.6 Criteria A is considered when spinal CSF leak is patient was transferred to the operating room. Base line demonstrated in any imaging modality by the presence vitals were recorded which was normal. The patient was of extrathecal CSF. If no spinal CSF leak can be shown, kept in left lateral position and under aseptic precaution; Criterion B can be considered if the brain features of epidural space was identified in C5-C6 space with loss of intracranial hypotension in addition to a low opening resistance technique using 18 G Tuohy needle. Then 15ml pressure (< 60 mmHg), spinal meningeal diverticulum or of blood was aspirated from left antecubital vein, which improvement of symptoms by epidural blood patch. If was injected slowly in the epidural space. After dressing, Criteria A and B are not met, Criterion C can be considered the patient was kept supine and observed for an hour and in the presence of all or at least two of the following: was uneventful. Patient was then shifted to general ward typical orthostatic headache, low opening pressure, spinal with advice to lie supine for 24 hours and check limbs meningeal diverticulum and symptomatic improvement power regularly. Over the next two days, the patient’s following epidural blood patch. In our patient, Criteria A headache slowly got relieved. There were no complications was present as MRI demonstrated a leak in dura in the noted. So patient was discharged home after three days cervical region. of procedure on as per need analgesics for headache. The The usual clinical course of BIH in most patients is patient was followed up at the out patient clinic after one spontaneous resolution over a period of weeks to week, then weekly for six weeks and monthly for six month months.6 Conservative management for headache in of discharge and he was completely relieved of headache BIH are similar to PDPH and include bed rest, analgesic, and did not require any analgesics. 48 Journal of Society of Anesthesiologists of Nepal JSAN 2016; 3 (1) sedatives, oral caffeine, intravenous hydration.1,7 For al. CSF hypovoluemia vs intracranial hypotension in 'spontaneous cases not responding conservative management, epidural intracranial hypotension syndrome'. Neurology 2003;60:941- saline infusion5 or epidural blood patch is the treatment.8,9 7. http://dx.doi.org/10.1212/01.WNL.0000049933.51044.81 Intrathecal saline infusion or artificial CSF should not be [PMID:12654957] expected to seal a CSF leak but may be required as an 5. Syed NA, Mirza FA, Pabaney AH, Hassan R. Pathophysiology and effective temporizing measure to restore CSF volume until management of Spontaneous Intracranial Hypotension - A Review. J the leak can be permanently repaired in patients who Pak Med Assos 2012;62:51-5. [PMID:22352103] require urgent treatment, such as those with a decreased consciousness level. 5 6. Schievink WI, Maya MM, Louy C, Moser FG, Tourje J. Diagnostic criteria for spinal CSF leak and intracranial hypotension.
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