Two patients with spontaneous intracranial hypotension who underwent epidural blood patches

The authors report two cases of patients with spontaneous intracranial hypotension who underwent a lumbar epidural blood patch and then a subsequent thoracic epidural blood patch. The first patient is a 55-year-old woman who presented with a one month history of orthostastic headache with tinnitus, weakness, nausea, and blurry vision. The patient underwent an MRI of the brain which demonstrated sub-acute on chronic bilateral convex subdural hematomas. A total spine MRI demonstrated a possible 5mm subdural hematoma within the dorsal subdural space at L5-S1 of an indeterminate age. An epidural blood patch was performed at the L4-5 level with minimal resolution of her symptoms. The patient underwent a repeat epidural blood patch at the T3-4 level which resulted in resolution of her symptoms. The second patient is a 66-year-old woman who presented with a one-week history of orthostatic left frontal and bilateral occipital headaches with neck pain, tinnitus, and nausea. The patient underwent an MRI of the brain which demonstrated diffuse smooth dural prominence with enhancement. MRI of the spine showed no abnormalities. The patient failed conservative management and an epidural blood patch at the L4-5 level was attempted with only transient relief of symptoms. The patient then underwent a T5-6 epidural blood patch with marked improvement in her symptoms. Spontaneous low CSF pressure headache is being recognized with increasing frequency. It is estimated to be 5 per 100,000 per year with a peak around 40 years of age. Treatment consists of conservative management and then consideration of an epidural blood patch. Some literature suggests site-directed epidural blood patch treatment but this requires further diagnostic procedures. With our patient encounters we suggest a thoracic epidural blood patch can be effective in cases in which lumbar epidural blood patches are not successful.