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CC BY-NC-ND 4.0 · Indian Journal of Neurosurgery
DOI: 10.1055/s-0043-1761428
Case Report

Spontaneous Intracranial Hypotension Due to CSF Leak at Multiple Spinal Levels—A Case Report and Literature Review

M.K. Saranraj
1   Department of Neurosurgery, Apollo Hospitals, Teynampet, Chennai, Tamil Nadu, India
,
K. Giridharan
1   Department of Neurosurgery, Apollo Hospitals, Teynampet, Chennai, Tamil Nadu, India
,
Sudhakshina Nathan 
1   Department of Neurosurgery, Apollo Hospitals, Teynampet, Chennai, Tamil Nadu, India
,
Nadasha M. Babu
1   Department of Neurosurgery, Apollo Hospitals, Teynampet, Chennai, Tamil Nadu, India
,
Mangaleswaran Balamurugan
1   Department of Neurosurgery, Apollo Hospitals, Teynampet, Chennai, Tamil Nadu, India
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Abstract

Introduction Spontaneous intracranial hypotension (SIH) is a misdiagnosed condition characterized by low cerebrospinal fluid (CSF) volume and an orthostatic headache that worsens with upright posture due to CSF leak at spinal dural defects. SIH due to CSF leak at multiple spinal levels is a rare condition, and only a few cases have been reported in the literature. Here, we report a case of SIH with a CSF leak at multiple spinal levels. The treatment options and efficacy of epidural blood patch (EBP) injection were discussed in this article.

Case Report A 36-year-old man presented with complaints of orthostatic headache for 2 months and a computed tomography myelogram demonstrated CSF leaks at multiple spinal levels through the dural defects at C5-C6, C6-C7, C7-T1, T1-T2 levels, and at L1, L2, L3, and L4 vertebral levels on the left side. He was managed with a targeted EBP injection and he improved symptomatically within 24 hours of the EBP injection.

Summary SIH is an entity that results from CSF leakage, often through spinal dural defects due to mechanical tear by osteophyte complex, disc prolapse, connective tissue disorders, CSF-venous fistula, and leaking meningeal diverticula. SIH can result from single or multiple dural leaks, but spinal leaks at multiple levels are uncommon. To the best of our knowledge, a total number of 163 cases have been reported in the literature so far. With good success rates, targeted EBP injection with autologous blood is an effective treatment option for both single-level and multiple-level spinal leaks.

Keywords

spontaneous intracranial hypotension - multiple spinal CSF leaks - epidural blood patch injection


Publication History

Article published online:
23 February 2023

© 2023. Neurological Surgeons' Society of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018; 38 (01) 1-211
    CrossrefPubMedGoogle Scholar
  • 2 Carlton Jones L, Butteriss D, Scoffings D. Spontaneous intracranial hypotension: the role of radiology in diagnosis and management. Clin Radiol 2022; 77 (03) e181-e194
    CrossrefPubMedGoogle Scholar
  • 3 Schievink WI, Maya MM, Moser F. et al. Multiple spinal CSF leaks in spontaneous intracranial hypotension: do they exist?. Neurol Clin Pract 2021; 11 (05) e691-e697
    CrossrefPubMedGoogle Scholar
  • 4 Upadhyaya P, Ailani J. A review of spontaneous intracranial hypotension. Curr Neurol Neurosci Rep 2019; 19 (05) 22
    CrossrefPubMedGoogle Scholar
  • 5 Shin HY. Recent update on epidural blood patch. Anesth Pain Med (Seoul) 2022; 17 (01) 12-23
    CrossrefPubMedGoogle Scholar
  • 6 Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache 2013; 53 (07) 1034-1053
    CrossrefPubMedGoogle Scholar
  • 7 Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Utility of heavily T2-weighted MR myelography as the first step in CSF leak detection and the planning of epidural blood patches. J Clin Neurosci 2020; 77: 110-115
    CrossrefPubMedGoogle Scholar
  • 8 Bhoi SK, Naik S, Gupta D, Pradhan PK, Kalita J, Misra UK. Recurrent spontaneous cerebrospinal fluid leaks at multiple levels. Neurol India 2021; 69 (06) 1828-1830
    CrossrefPubMedGoogle Scholar
  • 9 Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 2006; 295 (19) 2286-2296
    CrossrefPubMedGoogle Scholar
  • 10 D'Antona L, Jaime Merchan MA, Vassiliou A. et al. Clinical presentation, investigation findings, and treatment outcomes of spontaneous intracranial hypotension syndrome: a systematic review and meta-analysis. JAMA Neurol 2021; 78 (03) 329-337
    CrossrefPubMedGoogle Scholar
  • 11 Kim SY, Hong JH. Epidural blood patches in a patient with multi-level cerebrospinal fluid leakage that was induced by spontaneous intracranial hypotension. Korean J Pain 2010; 23 (01) 46-50
    CrossrefPubMedGoogle Scholar
  • 12 Piechowiak EI, Aeschimann B, Häni L. et al. Epidural blood patching in spontaneous intracranial hypotension-do we really seal the leak?. [published online ahead of print, 2022 Aug 26] Clin Neuroradiol 2022; ••• DOI: 10.1007/s00062-022-01205-7.
    CrossrefPubMedGoogle Scholar
  • 13 Arumugam G, Ram S, Naidu P B, Kumaravelu S. Epidural blood patch for spontaneous intracranial hypotension (SIH): a report of two cases. Trop Doct 2020; 50 (04) 369-373
    CrossrefPubMedGoogle Scholar