Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan.
Department of Anaesthesiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan.
Brain. 2017 Feb;140(2):344-352. doi: 10.1093/brain/aww328. Epub 2017 Jan 2.
Spontaneous intracranial hypotension results from cerebrospinal fluid leakage. Currently, the treatment of choice for spontaneous intracranial hypotension is the epidural blood patch, which has a variable response rate and no clear outcome predictors. This study aimed to identify predictors for response rate of a first targeted epidural blood patch in patients with spontaneous intracranial hypotension. We reviewed cases of patients with spontaneous intracranial hypotension who received targeted epidural blood patch at our hospital between 1 January 2007 and 1 July 2014. The outcome measure was first epidural blood patch response. We analysed demographics, clinical manifestations, neuroimaging findings (non-contrast heavily T-weighted magnetic resonance myelography and brain magnetic resonance imaging), and blood volume as potential outcome predictors. Significant predictors were tested and a decision tree was used to construct a predictive model. In total, 150 patients with spontaneous intracranial hypotension were included for final analyses. Their overall first targeted epidural blood patch response rate was 58.7%. Among patients with a greater injected blood volume (≥22.5 versus <22.5 ml), the response rate was higher (67.9% versus 47.0%, P = 0.01). In brain and spinal magnetic resonance imaging studies, significant predictors included anterior epidural cerebrospinal fluid collection length (<8 versus ≥8 segments; 72.5% versus 37.3%, odds ratio = 4.4, 95% confidence interval: 2.2-8.9, P < 0.001) and midbrain-pons angle (≥40° versus <40°; 71.3% versus 37.5%, odds ratio = 4.1, 95% confidence interval 2.1-8.3, P < 0.001). Decision tree analyses showed that patients with anterior epidural CSF collection involving <8 segments and an injected blood volume ≥22.5 ml had an 80.0% response rate. Patients with anterior epidural cerebrospinal fluid collection involving ≥8 segments and a midbrain-pons angle <40° had a 21.2% response rate. These three variables predicted first epidural blood patch response in 71.3% of patients. Brain and spinal neuroimaging findings and epidural blood patch blood volume can be used to predict targeted first epidural blood patch response in patients with spontaneous intracranial hypotension.
自发性颅内低血压是由于脑脊液漏引起的。目前，自发性颅内低血压的治疗选择是硬膜外血贴，其反应率各不相同，且无明确的预后预测指标。本研究旨在确定自发性颅内低血压患者首次硬膜外血贴治疗反应率的预测因素。我们回顾了 2007 年 1 月 1 日至 2014 年 7 月 1 日期间在我院接受硬膜外血贴治疗的自发性颅内低血压患者的病例。主要结局指标为首次硬膜外血贴反应。我们分析了人口统计学资料、临床表现、神经影像学表现（非对比性重 T 加权磁共振脊髓造影和脑磁共振成像）和血容量等潜在的预后预测因素。对有显著意义的预测因素进行了检验，并使用决策树构建了预测模型。共纳入 150 例自发性颅内低血压患者进行最终分析。他们的总体首次硬膜外血贴治疗反应率为 58.7%。在注入血容量较大（≥22.5 毫升与<22.5 毫升）的患者中，反应率更高（67.9%与 47.0%，P=0.01）。在脑和脊髓磁共振成像研究中，显著的预测因素包括硬膜外前部脑脊液集长度（<8 个节段与≥8 个节段；72.5%与 37.3%，比值比=4.4，95%置信区间：2.2-8.9，P<0.001）和中脑-脑桥角（≥40°与<40°；71.3%与 37.5%，比值比=4.1，95%置信区间：2.1-8.3，P<0.001）。决策树分析显示，硬膜外前部脑脊液集段<8 个节段且注入血容量≥22.5 毫升的患者反应率为 80.0%。硬膜外前部脑脊液集段≥8 个节段且中脑-脑桥角<40°的患者反应率为 21.2%。这三个变量可以预测 71.3%的患者首次硬膜外血贴治疗反应。脑和脊髓神经影像学表现和硬膜外血贴血量可用于预测自发性颅内低血压患者的首次硬膜外血贴治疗反应。
