Research Identifies Which Patients Benefit from Additional Testing to Find CSF Leaks

Newswise — Cerebrospinal fluid (CSF) hypovolemia (too little CSF) refers to a clinical condition where a spontaneous leak from the spine causes disabling positional headaches that worsen while upright and improve by lying down. In addition to headache, hypovolemia can lead to a reversible dementia syndrome. Although often unrecognized, CSF hypovolemia is diagnosed with brain MRI and treated with epidural blood patches, a procedure where blood is removed from the patient and then injected in the spinal epidural space, which is the spinal compartment immediately superficial to the cerebrospinal fluid space. This procedure is done in an attempt to seal the leak. Blood patches delivered directly to the site of CSF leak are more effective than non-site directed epidural blood patches delivered randomly and likely distant from the site of leak. However, diagnostic testing for discovering the site of leaks can be invasive and costly.  Researchers at Mayo Clinic sought to determine which CSF hypovolemia patients are better served by more intensive diagnostic testing upfront to find the specific leak site versus deferring testing and performing non-site directed epidural blood patches.

The study demonstrated that patients with brain MRI imaging with 4 or more specific CSF hypovolemia abnormalities and/or specific angle measurements of brain sagging on MRI imaging are not as likely to have a favorable epidural blood patch response.  Additionally, patients with extra-dural fluid on spine MRI were significantly more likely to have their site of leak identified with CT myelogram testing.  

In conclusion, patients with spinal epidural fluid on spine MRI, floridly abnormal brain MRI, and/or severe brain sag angles on MRI should have more dedicated diagnostic testing to find the specific leak site in order to allow targeted epidural blood patches to the leak site. Contrarily, it may be reasonable to initially perform non-site directed epidural blood patches in patients without significant disability or the above described imaging features, saving the patient from unnecessary and costly testing.

The study “Epidural Blood Patch (EBP) Efficacy Clinical Predictors in Spontaneous Cerebrospinal Fluid (CSF) Hypovolemia Patients” by Gabriel Pagani-Estevez, Jeremy Cutsforth-Gregory, Jonathan Morris, David Piepgras, Bahram Mokri, and James Watson will be presented at the 16^th Annual Pain Medicine Meeting on Friday November 17 at 2:15 pm. The abstract was selected to receive an ASRA Resident/Fellow Travel Award and will be presented at the Resident/Fellow Educational Program.