Targeted Epidural Blood Patch Under O-Arm-Guided Stereotactic Navigation in Patients with Intracranial Hypotension Associated with a Spinal Cerebrospinal Fluid Leak and Ventral Dural Defect

Abstract

Objective: Targeted epidural blood patch (EBP) at the site of a presumed cerebrospinal fluid leak reportedly has better outcomes than non-targeted EBP; however, it is associated with a higher risk of wrong-site injection, such as iatrogenic subarachnoid or intramuscular injections, which lead to reintervention because of the insufficient coverage of injected blood.

Methods: Eight patients with intracranial hypotension owing to a CSF leak diagnosed with myelographic computed tomography (CT) and thin-cut magnetic resonance imaging (MRI) received an epidural blood patch under O-arm-guided stereotactic navigation.

Results: The leak site was identified on the basis of myelographic CT findings of a micro-spur, epidural contrast medium extravasations, and MRI findings of a ventral dural defect. During the EBP procedure, no iatrogenic dural puncture or subarachnoid injection occurred because O-arm-guided stereotactic navigation provided real-time feedback on the needle trajectory. O-arm CT revealed the sufficient coverage of injected blood following the first injection in 6 of 8 patients. In the 2 remaining patients, a second injection was performed during the same session because of insufficient coverage at the previous site. In all patients, complete recovery from orthostatic headaches was achieved after a single session.

Conclusions: O-arm-guided navigation facilitated EBP by enabling real-time observations of the needle trajectory and distribution of injected blood while simultaneously avoiding major complications, such as wrong-site injections or reintervention.

Keywords: Cerebrospinal fluid hypovolemia; Computed tomography-myelography; Disc herniation; Epidural blood patch; Osteophyte.