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Epidural Blood Patch (EBP) Efficacy Clinical Predictors in Spontaneous Cerebrospinal Fluid (CSF) Hypovolemia Patients
Session: MP-02a
Thurs, Nov. 16, 10 am-12 pm
Hampton Room

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Epidural Blood Patch (EBP) Efficacy in Spontaneous Cerebrospinal Fluid (CSF) Hypovolemia

 

Abstract

Background and Objectives:

•Epidural blood patch (EBP) is a safe and effective treatment for spontaneous cerebrospinal fluid (CSF) hypovolemia
•Clinical predictors of EBP efficacy are lacking
•To investigate clinico-radiographic prognosticators of EBP efficacy

 

Methods:

•IRB-approved retrospective case-series excluding iatrogenic CSF hypovolemia
•202 patients receiving 604 patches were studied for dichotomized EBP efficacy defined at 3-months
•p < 0.05 was statistically significant

 

Results:

•Leak-site identification was associated with spinal epidural fluid (4.150(1.692-10.533);p=0.0018), younger age (1.044(1.004-1.090);p=0.0287) and absence of headache as the predominant symptom (3.777(1.297-11.241);p=0.0151)
•With spinal epidural fluid present, the diagnostic rate  was highest with dynamic CT myelography at 78%
•Negative EBP predictors: >=4 abnormal brain MRI findings(0.55(0.3-1.91);p=0.0367), brain sag vein of Galen/straight sinus (vG/SS) angle <58° (0.4(0.17 – 0.9);p =0.0274) and brain sag midbrain-pons (MP) angle <47° (0.37(0.14 -0.94);p=0.0373)
•Rebound intracranial hypertension was associated with longer EBP response (141(36 – 328) vs. 1(0 – 8) days; p<0.0001)
•Leak-targeted EBP were significantly more effective than blind patches (8.35(0.97 – 72.1);p = 0.0334)

Conclusions:

•Largest known cohort of spontaneous CSF leak patients studied for diagnostic-prognostic variables
•Spinal epidural fluid predicts finding the leak 
•Acute brain sag angles and >=4  brain MRI abnormalities predict poor EBP response 
•Clinico-radiographic variables can guide the clinician in deciding between blind EBP or further diagnostic studies to localize the leak for targeted EBP
 
 
Discussion
Predictors of identifying a leak: spinal epidural fluid (which needs to reflex to dynamic CT myelogram), younger age, absence of headache as predominant clinical manifestation
Negative predictors of successful EBP: >=4 brain MRI abnormalities (abnormalities include pachymeningeal enhancement, brain sag, pituitary enlargement, subdural fluid, venous engorgement) and acute vein of Galen/straight sinus (vG/SS) and midbrain/pons (MP) angles of brain sag
•Leak-targeted EBP are more successful than blind EBP
•Rebound intracranial hypertension is strongly successful of a successful EBP and not a failed one
•Of 39 patients with subdural fluid, only 1 (3%) worsened following EBP requiring craniotomy.  Subdural fluid is not an explicit contraindication to EBP.
•Quincke spinal needles (and not Whitacre) were used for diagnostic dural punctures; < 1% required EBP at the diagnostic dural puncture site
•Proposed Diagnostic Algorithm

1) Perform gadolinium enhanced brain and spine MRI in all patients with suspected spontaneous CSF hypovolemia.

2) Forego blind EBP and perform myelography with the intention of pursuing targeted EBP in patients with either moderate or greater amount of disability, acute angles of brain sag or  >4 brain MRI abnormalities.

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