Treatments
Spinal CSF leaks associated with medical procedures are
amenable to targeted treatment approaches.
It is suspected that a substantial percentage of
spontaneous cases resolve within days to weeks of onset
without any intervention. A brief course of a conservative
approach is often recommended if symptom severity and
complications do not preclude it. Consuming extra fluids
and generous amounts of caffeine, as well as bedrest may
reduce symptom severity. Medications often used for
migraine headaches are largely ineffective for the head
pain. Treatment directed to the underlying cause of spinal
CSF leak is needed when conservative measures fail.
Urgent treatment will be needed in cases with serious
complications, such as coma or a large subdural hematoma
(blood clot pressing on brain inside the skull).
Epidural blood patch (EBP) is a procedure used
routinely for post-dural puncture headache and is also the
mainstay of treatment for spontaneous spinal fluid leaks.
This may be performed after brain MRI with contrast
but with or without imaging of the spine. This imaging-
guided procedure involves the injection of the patient’s
blood into the epidural space (space just outside the dura)
in the lumbar and/or thoracolumbar region of the spine.
It may be repeated several times.
If the response to one or more epidural blood patches
is partial or if the symptoms relapse, spinal imaging is
performed to try to locate the leak for targeted treatment.
If evident on imaging, the leak location and characteristics
will dictate the best approach, whether that be epidural
patching targeted to the level of the leak or open surgical
repair. Targeted epidural patching is done with blood,
fibrin sealant (type of glue made from blood products),
or both. When spinal imaging is negative, non-targeted
epidural blood patches may be repeated or epidural
patching may be targeted at suspected leak locations.
Surgical repairs are necessary for some patients
depending on factors such as the leak type, leak location,
or for patients in whom other measures have failed
Prognosis
Following successful treatment, some patients develop
rebound intracranial hypertension or elevated intracranial
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Volume 7, Issue 1 • 2018
pressure. This scenario is usually self-limited but may last
for weeks or months, rarely for years. Treatment with
medications to lower intracranial pressure is occasionally
necessary.
While study of long-term outcomes remains limited,
most patients who receive treatment for intracranial
hypotension do well, with improved quality of life or a
complete cure. Negative spinal imaging, however, limits
treatment options for those with partial or temporary
response to epidural patching procedures. There are
patients, however, that endure persistent symptoms
despite multiple procedures.
Summary
A significant percentage of individuals with chronic
daily headache may actually be suffering from intracranial
hypotension secondary to a spinal CSF leak. These
individuals tend to have minimal response to treatments
normally used for primary headache disorders. Treatment
directed at the underlying cause can lead to improved
quality of life or a complete cure. As awareness of this
disorder rises, diagnostic delays are becoming shorter.
Earlier diagnosis and treatment are critical to reducing the
burden of suffering. HW
Recommended Reading
Schievink WI. Spontaneous spinal cerebrospinal fluid
leaks and intracranial hypotension. JAMA 2006;
295:2286–2296. http://jamanetwork.com/journals/
jama/fullarticle/202849
Mokri B. Spontaneous Intracranial Hypotension.
Continuum Minneap Minn 2015; 21:1086-1108.
https://www.ncbi.nlm.nih.gov/pubmed/26252593
Deline C, Schievink WI. Spontaneous Intracranial
Hypotension. Rare Disease Database Report.
2017 Jan. https://rarediseases.org/rare-diseases/
spontaneous-intracranial-hypotension/
Spinal CSF Leak Foundation Resources. http://
spinalcsfleak.org/resources
Kranz PG, Malinzak MD, Amrhein TJ, Gray L. Update
on the Diagnosis and Treatment of Spontaneous
Intracranial Hypotension. Curr Pain Headache Rep.
2017 Aug;21(8):37. https://www.ncbi.nlm.nih.gov/
pubmed/28754752