Epidural Blood Patch as a Diagnostic and Therapeutic Intervention in Spontaneous Intracranial Hypotension: A Novel Approach to Management.

Abstract

Spontaneous intracranial hypotension (SIH) remains a diagnostic and therapeutic challenge. Nonspecific clinical features and a reluctance to treat without confirmatory imaging evidence undermine management. Investigations are often insensitive and expensive, with many patients continuing to an epidural blood patch (EBP) despite negative results. Current diagnostic standards are based on a literature base skewed toward difficult-to-treat cases at specialty centers. This study aims to develop a robust diagnostic and treatment algorithm in real-life clinical practice by 1) investigating the prognostic utility of symptoms of SIH and results of associated investigation from which a scoring system is derived and 2) analyzing the role of EBP as a diagnostic and treatment tool. This is a retrospective study of 86 patients fulfilling clinical criteria for SIH and undergoing EBP, with follow-up ranging from 1 month to 15 years, using patient medical records and an online questionnaire. Although specific and prognostically significant, magnetic resonance imaging of the brain, magnetic resonance imaging of the spine, and symptom-based scoring systems were too insensitive to be of practical use. Most patients with positive and sustained responses to EBP did not meet current criteria for diagnosis. The 72-hour response to the first EBP was found to be highly specific and sensitive in the diagnosis of SIH in our cohort. This study supports the utility of EBP as a safe, accessible, and accurate diagnostic and therapeutic tool. We propose a simple treatment algorithm that facilitates diagnosis, treatment, and prediction of long-term outcomes in this challenging condition.