Background and Purpose Epidural blood patch has been the standard of care for treating Cerebrospinal fluid (CSF) leaks that fail conservative management whether it is related to post-dural puncture or spontaneous. The use of fibrin glue and mixed blood/fibrin patches have been described to be effective in multiple reports. However, in many cases of CSF leak, identifying the level(s) of the leak to direct the treatment poses a challenge leading to refractory symptoms post treatment, especially in spontaneous CSF leak. We describe a novel approach for treating refractory CSF leakage using peripherally inserted central catheter (PICC) lines in the epidural space.
Materials and Methods Two patients presenting with recurrent attacks of progressive positional headache (one spontaneous and one post traumatic) were proven by myelograms to be secondary to CSF leak. After failure of conservative management, epidural blood patch was decided.
Results In the post-traumatic patient, epidural contrast extravasation was seen in the ventral epidural space extending between C6 and T4 levels, centered at the T1/T2 disc space with 2 sites of leak suspected at C7/T1 and the other between T3 and T6 level. After 5 unsuccessful attempts of epidural blood and fibrin patches and failed hemilaminectomy with transpedicular repair over a 2-month period, a 4 F sheath was placed at L2/3 level followed by navigation of a diagnostic catheter over a guide wire to the upper thoracic levels, the catheter was then exchanged for a 4F PICC line and 13 cc of fibrin glue was injected all the way from T4 level down to L2/3 level. Following treatment, the patients‘ symptoms significantly improved with no further treatment required. In the other case of spontaneous CSF leak, 4 leakage sites were suspected; patient underwent 4 epidural blood and fibrin glue patches at various levels between T1 and L4, with none of which was successful in controlling the symptoms. Again, a PICC line inserted at L3/4 level was navigated to the craniocervical junction followed by fibrin glue injection in the epidural space from the craniocervical junction down to the upper lumbar level. The procedure was successful in achieving symptoms resolution. No post-procedure complications occurred in both patients.
Conclusions Epidural Fibrin glue injection using peripherally inserted central catheter (PICC) lines is a safe and effective approach for treatment of refractory CSF leaks with multiple or unconfirmed sites of leakage.
Disclosures R. Abdalla: None. D. Cantrell: None. M. Hurley: None. S. Ansari: None. A. Shaibani: None.
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