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Correspondence |
Nantes, France
To the Editor:
Spontaneous intracranial hypotension (SIH) is a rare syndrome, described for the first time in 1938 by Shaltenbrand.1 Spontaneous cerebral spinal fluid (CSF) leaks are the main etiology of SIH.2 It is a syndrome of low CSF pressure characterized by postural headaches in patients without any history of dural puncture or penetrating trauma. Neurologic symptoms are sometimes associated with vomiting, vertigo, photophobia and worsened by orthostatism. A CSF opening pressure less than 6 cm H2O is measured and there is a moderate increase in CSF protein level. Computed tomography (CT) is typically negative, sometimes revealing characteristic small ventricles, brain descent or subdural fluid collection.3 Brain magnetic resonance imaging (MRI) frequently objectivates a local or a diffuse pachymeningeal enhancement.3 Medullar MRI, radioisotope cis-ternography and CT-myelogram allow localization of the CSF leak.3 The development of MRI technology, explains the increasing number of SIH recognized by neurologists.
Various treatments have been used in SIH: supportive measures (bed rest, analgesics, caffeine and hydration), corticosteroids, continuous intrathecal saline infusion and blood patch (BP).3 There is no definite or agreed-on standard approach in the literature. Nevertheless, BP seems to be associated with a high rate of success: in the largest series, success ranged from 70 to 100%.3–5 Only two series of SIH are reported in the anesthesiology literature4,5 and the use of BP is often delayed. We report a prospective series of five patients with SIH treated systematically by BP.
All patients (five women) were admitted in a neurological unit for invalidating orthostatic headache associated with various neurologic signs (Table
). SIH was confirmed by brain MRI in all and by CSF-pressure measurement in two. All patients were treated by BP, performed by the anesthesiologist in the operating room. After insertion of a Tuohy needle at the lumbar level, 20 mL of autologous blood were injected. The BP was repeated 24 hr later if necessary until resolution of headache (maximum three BP; Table). All presented an immediate resolution of symptoms at the last BP, except one patient in whom a considerable decrease in pain and associated symptoms allowed return to a normal quality of life. Consequently, she refused another BP.
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References
1 Schaltenbrand G. Neuere anschauungen zur pathophysiologie des liquorzirkulation. Zentralbl Neurochir 1938; 3: 290–300.
2 Rando TA, Fishman RA. Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology 1992; 42(3 Pt 1): 481–7.
3 Chung SJ, Kim JS, Lee MC. Syndrome of cerebral spinal fluid hypovolemia. Clinical and imaging features and outcome. Neurology 2000; 55: 1321–7.
4 Benzon HT, Nemickas R, Molloy RE, Ahmad S, Melen O, Cohen B. Lumbar and thoracic epidural blood injections to treat spontaneous intracranial hypotension. Anesthesiology 1996; 85: 920–2.[Medline]
5 Weitz SR, Drasner K. Spontaneous intracranial hypotension: a series. Anesthesiology 1996; 85: 923–5.[Medline]
This article has been cited by other articles:
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  M.-L. Buguet-Brown, Y. Le Gulluche, A. Vichard, T. De Greslan, F. Olive, and Y. Diraison Spontaneous intracranial hypotension: a recent indication for epidural blood patch. Br. J. Anaesth., May 1, 2006; 96(5): 668 - 669. [Full Text] [PDF]
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