复发性自发性颅内低压（SIH）与重复硬膜外血贴（EBP）的持久性
Recurrent Spontaneous Intracranial Hypotension (SIH) and the Durability of Repeat Epidural Blood Patch (EBP).
作者信息
Hazama Ali, Awawdeh Fakhri, Braley Alexander, Loree John, Swarnkar Amar, Chin Lawrence S, Krishnamurthy Satish
机构信息
Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA.
Neurological Surgery, Lake Erie College of Osteopathic Medicine, Elmira, USA.
出版信息
Cureus. 2023 Jul 6;15(7):e41457. doi: 10.7759/cureus.41457. eCollection 2023 Jul.
OBJECTIVE
Spontaneous intracranial hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) of the dural sac is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate the recent efficacy and outcomes of EBP for SIH at our institution.
METHODS
Twenty-three patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018 at the same institution. All patients underwent brain MRI with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBP was placed one or two vertebral levels below areas of suspected leak, while the patient was positioned in the lateral decubitus position. Patients were seen in the outpatient setting within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 months following clinical relief of symptoms.
RESULTS
22/23 (95.7%) patients presented with complaints of orthostatic headache, and 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningeal enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had a subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, and 5/23 (21.7%) patients received further EBPs for persistent disease with all achieving relief after repeat EBP. 5/12 (41.7%) of patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient were 21.7 mL (median 20 mL, 7-40 mL) and 3.54 (median 1, 1-13) respectively. There was one complication from initial EBP (cervical dural tear requiring operative closure) treated with open surgical management successfully. In total, 18/23 (78.2%) patients are currently asymptomatic with regard to their SIH. The mean follow-up in this cohort was 2.6 years (median 1.8 years, 1.8 months-9.27 years).
CONCLUSIONS
EBP is a viable and effective option for the treatment of recurrent SIH caused by cerebrospinal fluid (CSF) leaks.
目的
自发性颅内低压（SIH）仍然是一种罕见且难以诊断和治疗的临床病症。硬膜囊硬膜外血贴（EBP）是难治性病例的主要确定性治疗方法，但其疗效不一。我们试图评估我院EBP治疗SIH的近期疗效和结果。
方法
2009年夏季至2018年春季，同一机构诊治了23例SIH患者（14例女性，9例男性，平均年龄49岁）。所有患者均接受了有无钆对比剂的脑部MRI检查以及T2加权脊柱MRI检查。在患者处于侧卧位时，将靶向EBP置于疑似渗漏区域下方一或两个椎体水平处。在初次EBP后一周内在门诊对患者进行诊治，对症状持续的患者进行重复EBP治疗。如果症状持续存在或在症状临床缓解后随访6个月。
结果
22/23（95.7%）的患者有直立性头痛主诉，3例（13%）患者有精神状态改变（AMS）或局灶性神经功能缺损。脑部MRI显示16/23（69.6%）的患者有硬脑膜强化，5/23（21.7%）的患者有硬膜下血肿（SDH）。18/23（78.3%）的患者成功识别出硬脑膜渗漏。12/23（52.2%）的患者初次EBP后症状缓解，5/23（21.7%）的患者因疾病持续接受进一步的EBP治疗，所有患者在重复EBP后均获缓解。5/12（41.7%）的患者在初次EBP缓解后出现复发症状，4/5（80%）的患者经第二次EBP成功治疗。每位患者初次EBP的平均体积和EBP次数分别为21.7 mL（中位数20 mL，7 - 40 mL）和3.54（中位数1，1 - 13）。初次EBP有1例并发症（颈椎硬脑膜撕裂需手术闭合），经开放手术成功处理。目前，18/23（78.2%）的患者SIH无症状。该队列的平均随访时间为2.6年（中位数1.8年，1.8个月 - 9.27年）。
结论
EBP是治疗脑脊液（CSF）漏引起的复发性SIH的可行且有效的选择。
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