Targeted Epidural Blood Patch Injection Through a Mini-Open Approach for Treatment of Spontaneous Intracranial Hypotension

Abstract

BACKGROUND AND OBJECTIVES: Spontaneous intracranial hypotension is recognized as a cause for refractory headache. Treatment can range from blind blood patch injection to microsurgical repair of the cerebrospinal fluid (CSF) leak. The objective of the study was to investigate the safety and efficacy of the targeted blood patch injection (TBPI) technique through a mini-open approach in treatment of refractory intracranial hypotension. METHODS: We retrospectively reviewed cases of 20 patients who were treated for spontaneous intracranial hypotension at our institute between 2011 and 2022. Head and spine MRI and whole-spine myelography were performed in an attempt to localize the CSF leak. All patients underwent implantation of two epidural drains above and beneath the index level through a minimally invasive interlaminar microsurgical approach under general anesthesia. Then, blood patch was injected under clinical surveillance. Treatment success and surgical complications were evaluated postoperatively and at follow-up. RESULTS: Patients presented with orthostatic headache, vertigo, sensory deficits, and hypacusis (95%, 15%, 15%, and 10%, respectively). Subdural effusions were present in 65% of the cases. A CSF leak was identified in all patients. The exact site of the CSF leak could be identified in 80% of cases. TBPI was performed with an average blood amount of 37.5 mL. A significant improvement of symptoms was reported in 90% of the cases. A total of 15% of the patients showed recurrent symptoms and underwent a second TBPI, resulting in symptom relief. No therapy-related complications were reported. CONCLUSION: TBPI is a safe and efficient treatment for spontaneous intracranial hypotension. It is performed in a minimally invasive procedure and can be repeated, if necessary, with a very low-risk profile.