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EPIDURAL BLOOD PATCH IN THE MANAGEMENT OF MEDICALLY-REFRACTORY CEREBROSPINAL FLUID HYPOVOLEMIA SYNDROME
ESRA Academy. SCIMIA P. Sep 8, 2016; 138295; 0121 Topic: Lumbar Epidural Anaesthesia - Analgesia
PAOLO SCIMIA
PAOLO SCIMIA

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Abstract
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Background and Aims:

The diagnosis of spontaneous cerebrospinal fluid hypovolemia (SCH) requires a high index of suspicion, meticulous history taking and neuroimaging features. We report a case of SCH syndrome successfully treated with epidural blood patching (EBP) after poor response to conservative management.

Methods:

A 46-year-old male, presented with subacute onset severe occipital headaches precipitated by upright posture, associated with neck pain, nausea,  tinnitus, vertigo, diplopia, photophobia. He was so incapacitated with his orthostatic headache that he was very fearful of getting off his bed for activities of daily living. There was no history of neurological deficit, trauma, cranial/spinal surgery. Clinical examination, CSF opening pressure and laboratory analysis were normal. Contrast MRI brain showed the presence of bilateral subdural hygromas, diffuse pachymeningeal enhancement, venous distension, and sagging of the brain. Patient did not respond to bed rest, analgesics and fluids. He was given EBP therapy involves the infusion of autologous blood 10 ml into the L4-L5 epidural space.

Results:

Patient responded remarkably to EBP with reduction of headache by 50% in 48 h followed by complete relief over days, and was headache free after 4 weeks with no recurrence on follow-up. MRI after 3 months revealed resolution of findings.

Conclusions:

SCH remains often underdiagnosed or misdiagnosed due to low index of suspicion. Majority of patients respond to conservative management based on avoidance of upright position, strict bed rest, liberal hydration, high caffeine intake, high salt intake, and addition of analgesics. EBP is the mainstay of treatment when conservative management fails.

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