Large-Volume Blood Patch to Multiple Sites in the Epidural Space through a Single-Catheter Access Site for Treatment of Spontaneous Intracranial Hypotension

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Fig 1.
Spot fluoroscopic image shows a 19-ga Tuohy needle at the L3 vertebral body with contrast opacifying the epidural space.
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Fig 2.
A and B, Frontal and lateral spot fluoroscopic images show a needle in the epidural space at L2 and a Glidewire curled in the epidural space in the lower thoracic spine. C, Frontal spot fluoroscopic image shows a 4F vertebral catheter that has been advanced over the wire in the epidural space from the L2 vertebral body to C4, with contrast opacifying the epidural space. D, Axial DynaCT shows the catheter and contrast opacifying the cervical epidural space.
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Fig 3.
A, Sagittal T1-weighted MR image shows descent (“sagging” or “sinking”) of brain, enlargement of the pituitary gland, and obliteration of the cisterns. B, Coronal postcontrast T1-weighted MR image of the same patient shows diffuse pachymeningeal enhancement.
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Fig 4.
A, Sagittal T1-weighted MR image 6 weeks after treatment shows an image of the brain with normal findings. B, Coronal postcontrast T1-weighted MR image after treatment shows resolution of the diffuse pachymeningeal enhancement.

Table 1:

Case characteristics

Patient	Age (yr)	Sex	Possible Imaging Leak Site^{^a}	Possible Causes	Symptoms
1^{^b}	39	F	Lower thoracic spine; L4–5	Lumbar fixation removed; Chiari s/p craniotomy; dural patch repair	Orthostatic HA
2^{^b}	59	F	Mid- or lower thoracic; no definite site	Chiari s/p craniotomy, prior traumatic pelvic fracture	Orthostatic HA, cochleovestibular manifestations, personality changes, frontotemporal dementia-like picture
3	21	M	Arachnoid cyst L1–L5; L2–3	None	Orthostatic HA
4	30	M	C6–T2	None	Orthostatic HA
5^{^b}	32	F	L2–3	None	Orthostatic HA
6^{^b}	37	F	Cervical, thoracic, upper lumbar	Dural tear during pregnancy	Orthostatic HA
7^{^b}	53	M	Multilevel cervical spine; T6–L1	Remote frontal head injury with LOC	Orthostatic HA, cochleovestibular manifestations, personality changes, memory decline, change in level of consciousness
8	22	F	Midthoracic; T12–L1	None	Orthostatic HA
9	9	F	Thoracic, lumbar, sacral	Chiari s/p craniotomy; Marfan syndrome	Orthostatic HA, nausea with emesis

Note:—s/p indicates status post: LOC, loss of consciousness; HA, headache.
↵a Determined by the attending diagnostic neuroradiologist or the treating neurointerventionalist using CT or MR myelography.
↵b Denotes a patient who had failed prior therapy.

Table 2:

Multisite epidural blood patch procedures and outcomes^{^a}

Patient	No. of Procedures	Access Site	Levels Injected	Volume Injected (Autologous Blood/DuraSeal) (mL/mL)	Follow-Up (mo)	Outcome^{^b}
1	3	L3; L3; L4	C5–L3; C5–L3; C5–L3	60/2; 55/3; 60	1	2b
2	2	L3; L3	C4–L3; C5–L3	60; 45/2	2	2c
3	1	L3	C4–L3	70	2	1
4	2	L3; L3	C3–L3; C5–L3	50; 65	1	2b
5	2	T12, L4; L4	C6–T12, L4; C3–L4	18, 20; 65	7	2a
6	5	T12, L3; L3; L2; L2; L4	C7–T12, L3; C3–L3; C3–L2; C6–L2; C6–L4	20, 18; 55; 45/0.5; 65/3; 70/3	1	3
7	2	T12, L4; L3	C7–T12, L2; C4–L3	18, 20; 60/1.5	4	2c
8	2	T12, L4; L1, L3	C5–T12, L4; C3–L1, L3	25, 20; 28, 20	2.5	2a
9	1	L4	C5–L4	50	0.25	1

↵a Data from separate procedures are noted by a semicolon.
↵b Outcomes: 1 = resolution without recurrence; 2a = improvement, recurrence, followed by resolution with subsequent treatment; 2b = stepwise improvement to resolution; 2c = improvement but not to resolution; 3 = transient improvement with worsening back to baseline; 4 = no improvement; 5 = worsening.