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Research ArticleSpine
Open Access

CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension

P.G. Kranz, L. Gray and J.N. Taylor
American Journal of Neuroradiology May 2011, 32 (5) 832-838; DOI: https://doi.org/10.3174/ajnr.A2384
P.G. Kranz
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L. Gray
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J.N. Taylor
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    Fig 1.

    Technique for CT-guided transforaminal blood patching. A, Needle placement before patching. The needle tip is located in the posterior third of the neural foramen, adjacent to a diverticulum of the nerve root (arrow). B, Contrast injected before blood patching confirms the location in the epidural space. C, Image obtained during injection of autologous blood demonstrates displacement of the contrast by the injected blood and mild mass effect on the diverticulum.

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    Fig 2.

    Resolution of imaging changes of intracranial hypotension. A, Pretreatment MR image shows typical signs of intracranial hypotension, including smooth dural thickening and enhancement (arrowheads) and subdural collections (arrows). B, Follow-up brain MR image after CT-guided targeted blood patching demonstrates resolution of dural enhancement and subdural collections.

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    Fig 3.

    Pre- and posttreatment MR imaging from patient 2. Dashed line indicates the foramen magnum. A, Pretreatment MR image demonstrates cerebellar tonsillar ectopia (arrow). The dashed line indicates the plane of the foramen magnum. Midline sagging of the brain with inferior displacement of the mammillary bodies is seen. In this patient, there was no abnormal dural enhancement on pretreatment MR imaging (not shown). B, Follow-up brain MR image after CT-guided blood patching demonstrates resolution of the cerebellar tonsillar ectopia and midline sag.

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    Fig 4.

    Pre- and posttreatment appearance of spinal fluid collections. A, Pretreatment CT myelogram from patient 6 demonstrates a subdural fluid collection (arrow) in the spinal canal, which narrows the CSF space. B, Follow-up CT myelogram 15 days after CT-guided blood patching at the site of leak demonstrates resolution of the subdural collection. C, Pretreatment CT myelogram from patient 3 demonstrates an extradural collection ventral to the thecal sac, extending into the nerve root sleeves (arrow). D, Follow-up CT myelogram 17 days after CT-guided blood patching of the nerve root sleeves demonstrates near-complete resolution of the collection.

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    Fig 5.

    Representative examples of targets for blood patching. A, CT myelogram demonstrates extravasation of contrast from a nerve root sleeve (white arrow) due to a high-flow leak. Note the presence of an extradural collection surrounding the thecal sac (black arrow). B, CT myelogram in a different patient demonstrates an enlarged diverticulum of the nerve root sleeve (arrowhead). Although no direct myelographic evidence of leak is seen, this site was chosen for empiric blood patching on the basis of the potential for an intermittent or low-flow leak.

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    Table

    Findings of CT myelographya

    Patient No.Opening Pressure (cm H20)Spinal Fluid CollectionIrregular DiverticulaDirect Visualization of LeakLocation of Diverticula
    CervicalUpper Thoracic (T1–6)Lower Thoracic (T6–12)Lumbar
    10+++0400
    215–+–0120
    30+–+0500
    4N/A–+–0070
    5N/A–+–0020
    60+++0010
    70–+–0251
    812–+–0145
    • Note: a + indicates presence of the finding; –, absence of the finding.

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American Journal of Neuroradiology: 32 (5)
American Journal of Neuroradiology
Vol. 32, Issue 5
1 May 2011
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CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension
P.G. Kranz, L. Gray, J.N. Taylor
American Journal of Neuroradiology May 2011, 32 (5) 832-838; DOI: 10.3174/ajnr.A2384

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CT-Guided Epidural Blood Patching of Directly Observed or Potential Leak Sites for the Targeted Treatment of Spontaneous Intracranial Hypotension
P.G. Kranz, L. Gray, J.N. Taylor
American Journal of Neuroradiology May 2011, 32 (5) 832-838; DOI: 10.3174/ajnr.A2384
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  • A classification system of spontaneous spinal CSF leaks
  • Imaging Signs in Spontaneous Intracranial Hypotension: Prevalence and Relationship to CSF Pressure
  • MR Myelography for Identification of Spinal CSF Leak in Spontaneous Intracranial Hypotension
  • Large-Volume Blood Patch to Multiple Sites in the Epidural Space through a Single-Catheter Access Site for Treatment of Spontaneous Intracranial Hypotension
  • Spinal Meningeal Diverticula in Spontaneous Intracranial Hypotension: Analysis of Prevalence and Myelographic Appearance
  • CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage
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