Slides
Transcript
Thank you Eike. I think it’s a difficult talk after Jürgen’s presentation telling you epidural blood patch is not a good option. But if I take a paper from Ian Carroll, epidural blood patch is the first option. He says “Okay, what is the difference?” There are many possible indications. Some have disappeared with Jürgen’s work and Wouter’s work. But we should have in mind that in the past we had to cure patients, and there are many institutions where you had to cure patients that cannot be operated because they don’t have a surgeon who will operate.
And this was actually the first cases we, I worked with. For example, this patient who got unresponsive and sitting upright. And what you can see – the rare midbrain changes. So I convinced the surgeon to do a CT myelogram. We did not know to find the leak exactly at this point of time, but we did several level CT-guided fibrin injection. The patient recovered. So that is still a chance to treat the patient, especially when he is getting really serious.
So what I learned from this, I try to inject as much contrast and blood, I think, but contrast as possible, and I try to find out a way that the contrast is really flowing upwards. You see that is the force needle position in this person. So if you start and you see that the blood or the contrast is not distributing freely in the epidural space, you won’t be satisfied. And at this time we did at several levels of the spine, cervical, thoracic, lumbar spine, just one single slice to see if the contrast in the epidural space is really there. If it’s not there and it stays down in the lower lumbar level, you won’t reach what you want to reach.
This is maybe a case with a bony spur at the T1–T2 level. We had the CT myelogram, we had the epidural contrast. We see that the epidural contrast reaching the bony spur, and so it’s 50 ml blood at this level, and you see that the SLEC sign disappeared one day after the epidural blood patch. So it may work in some cases. The number of 10% is probably true, but it can work if you get the contrast and hopefully the blood at the level.
Another case, the same situation where the egress in the in the extra thecal space here and you have the epidural contrast around here. But this was a young lady who said, “I have not any benefit from this procedure.” And she went to surgery like many patients do. And this is even true if you have other options like ventral CT-guided patches where you really can see that you fill contrast and blood in, not only the epidural space, but also in the sub-arachnoid space, and then surgery shows a hole and you’re disappointed about that.
Maybe if there is only a low leak, low-flow leak or not leaking really much, like in this case, you have the chance to get from lateral approach and can heal this ventral dural leak. So taken together, that is the paper from Eike who showed that none of these patients with a ventral dural tear had benefit or the SLEC’s not disappeared. This is not always the case, but I mean in 90% of cases.
So for type 1 leaks, ventral dural tears, surgery is the first-line option and not the epidural blood patch, which is due to the membrane formation Jürgen Beck showed in the presentation before.
I don’t have experience with organized versus non-organized SLECs, which was introduced by Callen. Well we’ll see whether it makes a difference. But again, the treatment success of the organized SLECs was not in a high range.
Type 2 leaks. We don’t use the term cyst any longer because we think it’s always a arachnoid herniation and it depends on the size of the hernia whether a blood patch can work or not. The goal is to build the herniated tissue with contrast, blood, or fibrin. And it may work even when the hernia does not disappear. We have lost this patient, but after 2 years he says he feels good again and no need to come back.
Type 3 fistulas, I don’t have much experience. We don’t know. Again, Jürgen is operating very early. Does a transvenous embolization make sense? Does a CT-guided fibrin injection make sense? To be honest, I do not know.
Then post-dural puncture headache. We talk about post-dural puncture headache without separating patients with unintended dural puncture, who often have a SLEC sign, mainly in the dorsal epidural space. These patients benefit from epidural blood patching.
Can you please start the videos again showing that the contrast is really flowing upwards? If it does not go upward, this does not make sense to inject. Like you see, the second column does not produce contrast going upward. So we did another injection one level above, and then we can show that the contrast is freely flowing upwards. And here you can see that the SLEC sign rapidly disappears. Left side before, right side after epidural blood patch. And you also can see that the SIH signs on the MRI scan disappear.
But we know that many patients with post-dural puncture headaches, and not an unintended dural puncture, do not have any signs of, any Bern scores, and any signs of hypotension on the MRI scans. And we have also had these patients in mind where we know we are running into a catastrophe, like this patient who had Lyme disease. Two years later he again complained of paresthesia, hand, finger, legs, not SIH sign, and we didn’t know did he have Borrelia-associated polyneuropathy or post-dural puncture headache or just nothing. MRI scan was either suggestive of hypertension, not hypotension.
So these are a lot of patients who come and say, “I want to have the epidural blood patch exactly at the site where the lumbar puncture was before.” And you know – you show him everything, where to puncture, does the contrast distribute in the epidural space, that you perfectly can show in the CT scan, that’s where you want to have it. And you know the patient comes back and complains that after the blood patch the symptoms got even worse. Well, that is a group of patients we should not neglect.
We worked with platelet rich fibrin in order to get better with the distribution, but this does not work. It’s not really a difference to the distribution to the clotting blood.
So one indication that remains for epidural blood patching is a frontotemporal brain sagging syndrome. Some call it brain sagging dementia. I call it spinal dementia. It doesn’t make a difference. Why is that an option? You can see even after a first epidural blood patch that the brain is getting upwards. The sagging is not disappearing. But it’s getting better and the patients do a lot better than you would expect from the MRI scans.
Why do the patients behave so completely different? We do not know. It’s probably related to the suction of the frontal basal lobe, innominate substance and from the herniation of the hippocampal head downwards.
But this is a completely different MRI scan in these group of patients. We are happy if we have this situation that we find a CSF-venous fistula and we can treat them with trans-venous embolization and the brain is again getting upwards. But we know from Wouter Schievink’s work that in two-thirds of patients no CSF leak is found, and even if that is a good theory we haven’t proven it yet. Many of these patients just benefit from epidural blood patches. Like you can see here, there is not really a tremendous improvement, but the patients do better than the MRI images suggest.
Some words, that is like leaky skull, leaky skull, very leaky. Why is that interesting? Because at this time it was only a small plane, 500 cc, and now we have a large plane and the variance of the skull is not really perfect. So why do we get a spinal CSF leak? Okay, I compare with a bicycle tube. You have a bony spur or the nail, then you have a type 1 leak. If we have an old bicycle tube, have tissue weakness, you rather get a type 2 leak. And if the pressure is too high, you may get a CSF-venous fistula, and you also may get a leak from pre-existing IIH. We did neglect that in the past.
CSF-venous fistula pre-visualization works, so that gives a hint that high pressure is maybe present at first. But if you have a leak from pre-existing hypertension, you never will prove it because the CSF pressure can be normal again, and the IIH signs may have disappeared.
Some example. Here – IIH. A lumbar puncture, hypertension, and she had a type 2 leak. What was first? First was the hypertension and then the type 2 leak resulted from pre-existing hypertension. And if you treat her with epidural blood patch, you will see that she develops hypertension again. So the epidural blood patch in this situation is only a measure to rearrange the disequilibrium of these patients. You see the type 2 or the herniation still exists, but the patient has no hypertension.
This is one of the rare patients we can prove that hypertension was first because this was a patient in a study. It’s not related to any symptoms. She had severe IIH signs. Then she developed hypertension and a leak, only a small leak. She was treated surgically, and again she had severe hypertension.
Another patient, a type 2 leak treated with a CT-guided fibrin patch. The herniation was maybe smaller, but the epidural fluid disappeared and she again developed severe idiopathic intracranial hypertension. Again, here’s the peers.
So we always talk about rebound intracranial hypertension in one-third of patients. Maybe some of them are related to pre-existing idiopathic intracranial hypertension.
So the summary of my talk is the current indication, at least in my book, and this may be different. We perform epidural blood patches in post-dural puncture headaches, in type 2 leaks if they have small arachnoid herniations, in sacral leaks where we cannot really prove where the leak is, and in spinal dementia with no leak. We inject as much blood as possible and check that the contrast flows upwards. We prefer fibrin injection if the leak is identified, and we aim at sealing the leak and increasing the epidural space pressure.
Thank you for your attention.