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Postsurgical pseudomeningoceles are extradural collections of cerebrospinal fluid (CSF) that results following an intraoperative dural breach. Although usually asymptomatic and self-subsiding, they may present with symptoms of postural headache, blurred vision, diplopia, photophobia, back pain, radiculopathy, and vomiting. Most of the cases recover with conservative measures such as bed rest, hydration, and pressure dressings. Symptomatic patients usually require surgical re-exploration and direct open repair of the durotomy. We report the case of a 48-year-old female who presented with lumbar pseudomeningocele following lumbar microdiscectomy treated by Ultrasoundguided (USG)-guided epidural blood patch application. She had globular swelling at the surgical site, postural headache, and left lower-limb radicular pain with normal neurology. Her magnetic resonance imaging (MRI) showed a left L4 laminar defect with pseudomeningocoele (measuring 5.5 cm × 4.2 cm × 4 cm) with intraspinal communication. USG was used to guide the aspiration of CSF from pseudomeningocele and to apply the epidural blood patch one level above and at the level of laminectomy. Postoperatively, she had marked improvement in her symptoms. At 1-year follow-up, she was completely symptom free and full resolution of pseudomeningocele was seen on 1-year follow-up MRI. This case is being reported to highlight the use of USG-guided epidural blood patch for the treatment of postoperative lumbar pseudomeningocele. [ABSTRACT FROM AUTHOR]

A patient receiving mechanical ventilation with multiple left hydropneumothoraces had a persistent air leak through the thoracostomy tube. The leak was temporarily resolved by interventional bronchoscopy at the bedside in the ICU. Because of the limited resources available at the hospital, a Swan-Ganz catheter was inserted into the left upper lobe bronchus, inflated and left in place. The air leak ceased and the left upper lobe bronchus was occluded with an autologous blood plug by infusing the patient’s own blood through the distal port of the catheter. The patient’s oxygenation improved significantly. The effects persisted for 2.5 hours until the air leak returned while the patient remained intubated. Such a technique may be useful when managing persistent air leaks.

Introduction. Post-dural puncture headache is classified as a secondary headache attributable to non-vascular intracranial disorders and belongs to the group of headaches caused by low cerebrospinal fluid pressure. Etiopathogenesis. The pathogenesis is not completely clear, but it is thought to be caused by the cerebrospinal fluid leak through the duct opening. Cerebrospinal fluid efflux leads to a decrease in intracranial pressure and stretching of the pain sensitive intracranial structures. A drop in intracranial pressure can cause compensatory cerebrovascular vasodilation, contributing to the onset of a headache. Diagnosis and Therapy. Post-dural puncture headache clinically presents as an orthostatic headache. In most cases, the diagnosis is made based on a typical clinical picture and it can be confirmed by magnetic resonance imaging and measurement of cerebrospinal fluid pressure. The condition is usually benign, most often with spontaneous recovery. The therapy involves conservative treatment, medications, as well as some invasive methods: epidural blood patches, blockage of the greater occipital nerve, and in most severe cases, epidural injection of fibrin sealant or surgical dural repair. Conclusion. Post-dural puncture headache is a common complaint in the clinical practice of neurologists and anesthesiologists. The prognosis is usually favourable, while the therapy may include conservative or invasive treatment procedures. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis investigated post-biopsy manoeuvres to reduce pneumothorax following computed tomography-guided percutaneous transthoracic lung biopsy. Twenty-one articles were included with 7080 patients. Chest drain insertion rates were significantly reduced by ninefold with the normal saline tract sealant compared to controls (OR 0.11, 95% CI 0.02-0.48), threefold with the rapid rollover manoeuvre to puncture site down (OR 0.34, 95% CI 0.18-0.63), threefold with the tract plug (OR 0.33, 95% CI 0.22-0.48) and threefold with the blood patch (OR 0.39, 95% CI 0.26-0.58). The absolute chest drain insertion rates were the lowest in the normal saline tract sealant (0.8% vs 7.3% for controls), rapid rollover (1.9% vs 5.2%), deep expiration and breath-hold on needle extraction (0.9% vs 1.8%) and standard rollover versus no rollover (2.6% vs 5.2%). These findings highlight post-biopsy manoeuvres which could help reduce pneumothorax and chest drain insertions following lung biopsies. LEVEL OF EVIDENCE: Level 1/no level of evidence, systematic review. [ABSTRACT FROM AUTHOR]

Spontaneous intracranial hypotension (SIH) is a syndrome in which hypovolemia of the cerebrospinal fluid (CSF) results in various symptoms. Although its prognosis is usually benign, cases with a rapid neurologic deterioration resulting in an altered mental status have been reported. One of the characteristic radiographic findings in such cases is the presence of bilateral accumulation of subdural fluid (hematoma/hygroma). When SIH-related subdural hematoma is present only unilaterally with a concomitant midline shift, making an accurate diagnosis may be challenging, and inadvertent hematoma evacuation may result in further neurologic deterioration. We report a 58-year-old woman with an altered mental status who had visited a local hospital and in whom a brain CT showed a unilateral subdural hematoma with a marked midline shift. She was referred to our department because of her neurologic deterioration after hematoma evacuation. A CT myelography revealed a massive CSF leakage in the entire thoracic epidural space. She made a full neurologic recovery following blood patch therapy. Our case is unique and educational because the suspicion for SIH as an underlying cause of subdural hematoma is warranted in nongeriatric patients not only with bilateral but also unilateral lesions. An immediate search for CSF leakage may be important in cases with failed hematoma evacuation surgery.

Introduction: Dural puncture occurs in 0.5 to 2% of epidural blocks with an incidence of post-puncture headache of 70 to 85%. The blood patch is considered the gold standard in the treatment, currently using 15 to 20 milliliters of autologous blood. Material and methods: In a series of cases of patients with dura puncture in a private gy-necological-obstetric hospital in Mexico City, from January 2015 to December 2016, the manage-ment was reported on an excel basis. carried out, the start time after the event and the volume of autologous blood used. Results: Twenty-fi ve patients with dura mater puncture from a total of 2,514 neuraxial anesthesia were included. The management of dura puncture was with a blood patch in 52% of cases and conservative in 48%. The mean time from dura puncture to treatment was fi ve hours (SD 3.02, two to 12 hours) for conservative treatment and 29.5 hours (10.5, 24-48 hours) for treatment with blood patch (p < 0.001, U of Mann Whitney). The average volume of autologous blood used was 8.85 mL. Discussion: We observed that it is not necessary to use volumes of 15 to 20 milliliters to achieve success in the remission of the symptomatology, low volumes of 6 to 12 milliliters became effec-tive. [ABSTRACT FROM AUTHOR]

Subdural hematoma (SDH) following labor epidural analgesia is a rare neurological complication. SDH is a late complication of this procedure; it is caused by a leak of cerebrospinal fluid that may damage the vascular structures of the brain. Persistent headache in the days after labor epidural analgesia is a nonspecific clinical symptom caused by hematoma. Preexisting vascular malformations can be a concomitant cause of headache. Clinical cases have been reported even after epidural anesthesia. The differential diagnosis includes unspecified headache, sinusitis headache, drug-induced headache, cortical vein thrombosis, fistula of the dura mater, and bacterial, viral, and aseptic meningitis. [ABSTRACT FROM AUTHOR]

Instillation of an autologous blood patch for prolonged air leak (PAL) in chest tube system has been studied and determined to be a safe and effective treatment plan for adults. The current recommended treatment guidelines for a PAL in adolescent secondary to a spontaneous pneumothorax are surgical intervention. This paper serves as documentation of two case reports with successful treatment of PALs with autologous blood patch in two adolescent patients. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy of a fluoroscopy-guided epidural blood patch (EBP) in the treatment of a post-dural puncture headache (PDPH). Materials and Methods: From November 2013 to April 2017, a total of 164 patients (76 males, 88 females, mean age 40.7 years, age range 12 to 87 years) underwent a fluoroscopy guided EBP for the treatment of PDPH in the department of radiology. The treatment outcomes were classified as follows: complete relief, incomplete relief, failure, and recurrence. In the case of recurrence, the duration between the date of the first EBP and the date of recurrence was described. The effectiveness of the second EBP was also evaluated. Results: In 164 PDPH patients, complete relief was achieved in 157 patients (95.8%), incomplete relief was achieved in 1 patient (0.6%), failure in 2 patients (1.2%) and recurrence in 4 patients after the first EBP. All 4 recurrence patients and the 2 failure patients were discharged with complete relief after receiving one additional EBP. Conclusion: In patients with PDPH, a fluoroscopy-guided EBP is an effective treatment. Moreover, an additional EBP can be considered in the clinical failure or recurrence of PDPH after the first EBP. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy of a fluoroscopy-guided epidural blood patch (EBP) in the treatment of a post-dural puncture headache (PDPH). Materials and Methods: From November 2013 to April 2017, a total of 164 patients (76 males, 88 females, mean age 40.7 years, age range 12 to 87 years) underwent a fluoroscopy guided EBP for the treatment of PDPH in the department of radiology. The treatment outcomes were classified as follows: complete relief, incomplete relief, failure, and recurrence. In the case of recurrence, the duration between the date of the first EBP and the date of recurrence was described. The effectiveness of the second EBP was also evaluated. Results: In 164 PDPH patients, complete relief was achieved in 157 patients (95.8%), incomplete relief was achieved in 1 patient (0.6%), failure in 2 patients (1.2%) and recurrence in 4 patients after the first EBP. All 4 recurrence patients and the 2 failure patients were discharged with complete relief after receiving one additional EBP. Conclusion: In patients with PDPH, a fluoroscopy-guided EBP is an effective treatment. Moreover, an additional EBP can be considered in the clinical failure or recurrence of PDPH after the first EBP. [ABSTRACT FROM AUTHOR]

Cerebral venous thrombosis (CVT) is a rare complication of lumbar puncture. Occasionally, the clinical picture of CVT may mimic post-dural puncture headache (PDPH) resulting in delayed diagnosis. A case of PDPH progressing to CVT is presented and the pathophysiology, diagnostic challenges and management options discussed in this article.

Ascites, the fluid accumulation in the peritoneal cavity, is most commonly seen in patients with end-stage liver disease (ESLD). Evaluating ascites or providing symptomatic relief for patients is accomplished by performing a paracentesis. Ascites leak from a paracentesis site can be a complication of the procedure and is associated with increased morbidity. Currently, the best options for these patients include medical management or surgical abdominal wall layer closure. Utilizing a blood patch provides an alternative approach to managing such patients. A two-center prospective case series was performed evaluating the efficacy of the blood patch in patients with significant persistent ascites leak following a paracentesis. About 30 mL of the patients’ peripheral blood was used for the blood patch. Subjects were recruited over a period of one year and followed for 30 days after the procedure. A total of six patients were recruited for this study. Subjects underwent placement of autologous blood patch at the site of the ascites leak and 100% had resolution of the leak within 24 h. None of the subjects developed any complications of the procedure. This study shows that an autologous blood patch is an effective, low-risk treatment method for ascites leaks following a paracentesis. It is a simple bedside procedure that can reduce morbidity in patients with end-stage liver disease.

Introduction: The cerebrospinal fluid leak (CSF) is defined as the loss of continuity of the dura, which generates the leak of CSF to paraspinal tissues. The incidence of this entity after open spine surgery is low and decreases even more in microsurgery procedures. The management objective is to correct the CSF leak. Late submission is rare and is primerily associated with the presence of osseous remains in the surgery field nearby the peridural space. The definitive management is the primary surgical repair, however, other less invasive treatments such as blood patch are reported in the literature with satisfactory results; this has proven to be a good therapeutic tool for CSF leak in recent years. Case report: The case is a 46 female with cerebrospinal fluid leak posterior a L5/S1 laminotomy with microsurgery, presenting this complication after she was discharged from the hospital, a blood patch was placed and absolute rest was given for 48 hours without CSF Leak improvement, so microsurgical correction was decided with good improvement. Discussion: We disccused in this article the different treatment options for CSF leak management, secondary to spinal surgery, including administration of a blood patch, the analysis of failure factors, different techniques and potential complications. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective chart review with limited prospective follow-up survey.Objective: To evaluate the efficacy and safety of blood patch injection for the treatment of positional headaches caused by postoperative lumbosacral pseudomeningoceles.Summary Of Background Data: Pseudomeningocele is one of the most common complications after posterior lumbosacral spinal surgery. Common treatments include bedrest, abdominal binder use, subarachnoid lumbar drainage, and surgical re-exploration for durotomy closure. To date, only small case reports support the use of epidural blood patch injection for symptomatic pseudomeningocele treatment.Methods: A retrospective chart review analyzed the outcomes and complications of 19 consecutive patients who underwent blood patch injection, with and without pseudomeningocele aspiration, for symptomatic postoperative lumbosacral pseudomeningoceles between 2009 and 2015. An attempt was made to survey patients by phone regarding satisfaction.Results: As of last follow-up (average time = 22.3 months), 16 patients (84%) experienced headache resolution after blood patch injection and did not require further treatment of their pseudomeningocele. In addition to symptomatic improvement, 12 of the 16 successful patients had imaging, which demonstrated pseudomeningocele resolution. Persistent pseudomeningoceles were demonstrated on imaging among all three unsuccessful patients.Conclusion: Pseudomeningocele aspiration followed by blood patch is an effective treatment for symptomatic postoperative lumbosacral pseudomenigocele. This is a minimally invasive alternative to surgical re-exploration with durotomy closure. Injections are most effective when performed early after pseudomeningocele development.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background Spontaneous intracranial hypotension (SIH) is a condition of low cerebrospinal fluid volume and pressure caused by a leak of cerebrospinal fluid through a dural defect. Diagnosis and management can be difficult, often requiring coordination between multiple disciplines for myelography, blood patching, and possible surgical repair. Patients should be monitored closely, because they can deteriorate into a coma or even death. There are no widely accepted guidelines for the management of SIH. Methods and Conclusions We review the existing SIH literature, illustrate management challenges via a case review, and propose an algorithm developed by neurosurgeons, radiologists, and anesthesiologists intended to simplify and streamline the management of SIH. [ABSTRACT FROM AUTHOR]

Background Spontaneous intracranial hypotension (SIH) is a more common than previously noted condition (1–2.5 per 50,000 persons) typically caused by cerebrospinal fluid (CSF) leakage. Initial treatment involves conservative therapies, but the mainstay of treatment for patients who fail conservative management is the epidural blood patch (EBP). Subdural hematoma (SDH) is a common complication occurring with SIH, but its management remains controversial. Methods In this report, we discuss a 62-year-old woman who presented with a 5-week history of orthostatic headaches associated with nausea, emesis, and neck pain. Despite initial imaging being negative, the patient later developed classic imaging evidence characteristic of SIH. Magnetic resonance imaging was unrevealing for the source of the CSF leak. Radionuclide cisternography showed possible CSF leak at the right-sided C7-T1 nerve root exit site. After failing a blind lumbar EBP, subsequent targeted EBP at C7-T1 improved the patient's symptoms. Two days later she developed a new headache with imaging evidence of worsening SDH with midline shift requiring burr hole drainage. This yielded sustained symptomatic relief and resolution of previously abnormal imaging findings at 2-month follow-up. Results A literature review revealed 174 cases of SIH complicated by SDH. This revealed conflicting opinions concerning the management of this condition. Conclusions Although blind lumbar EBP is often successful, targeted EBP has a lower rate of patients requiring a second EBP or other further treatment. On the other hand, targeted EBP has a larger risk profile. Depending on the clinic situation, treatment of the SDH via surgical evacuation may be necessary. [ABSTRACT FROM AUTHOR]

• Combined ABP-IPR did not reduce pneumothorax or chest drainage compared to IPR alone and may be a safer approach following CT-guided lung biopsy. • Pneumothorax predictors adjusted for ABP-IPR and IPR alone included age, lesion size, location, patient position, emphysema, and lesion-pleura distance, • Chest drainage predictors adjusted for ABP-IPR and IPR alone included lesion location, patient position, bullae crossed and lesion-pleura distance. The purpose of this study was to evaluate a combined autologous blood-patch (ABP)-immediate patient rollover (IPR) technique compared with the IPR technique alone on the incidence of pneumothorax and chest drainage following CT-guided lung biopsy. In this interventional cohort study of both prospectively and retrospectively acquired data, 652 patients underwent CT-guided lung biopsy. Patient demographics, lesion characteristics and technical biopsy variables including the combined ABP-IPR versus IPR alone were evaluated as predictors of pneumothorax and chest drain rates using regression analysis. The combined ABP-IPR technique was performed in 259 (39.7 %) patients whilst 393 (60.3 %) underwent IPR alone. There was no significant difference in pneumothorax rate or chest drains required between the combined ABP-IPR vs IPR groups (p =.08, p =.60 respectively). Predictors of pneumothorax adjusted for the combined ABP-IPR and IPR alone groups included age (p =.02), lesion size (p =.01), location (p =.005), patient position (p =.008), emphysema along the needle track (p =.005) and lesion distance from the pleura (p =.02). Adjusted predictors of chest drain insertion included lesion location (p =.09), patient position (p =.002), bullae crossed (p =.02) and lesion distance from the pleura (p =.02). The combined ABP-IPR technique does not reduce the pneumothorax or chest drain rate compared to the IPR technique alone. Utilising IPR without an ABP following CT-guided lung biopsy results in similar pneumothorax and chest drain rates while minimising the potential risk of systemic air embolism. [ABSTRACT FROM AUTHOR]

Objective: Spontaneous intracranial hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) of the dural sac is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate the recent efficacy and outcomes of EBP for SIH at our institution., Methods: Twenty-three patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018 at the same institution. All patients underwent brain MRI with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBP was placed one or two vertebral levels below areas of suspected leak, while the patient was positioned in the lateral decubitus position. Patients were seen in the outpatient setting within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 months following clinical relief of symptoms., Results: 22/23 (95.7%) patients presented with complaints of orthostatic headache, and 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningeal enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had a subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, and 5/23 (21.7%) patients received further EBPs for persistent disease with all achieving relief after repeat EBP. 5/12 (41.7%) of patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient were 21.7 mL (median 20 mL, 7-40 mL) and 3.54 (median 1, 1-13) respectively. There was one complication from initial EBP (cervical dural tear requiring operative closure) treated with open surgical management successfully. In total, 18/23 (78.2%) patients are currently asymptomatic with regard to their SIH. The mean follow-up in this cohort was 2.6 years (median 1.8 years, 1.8 months-9.27 years)., Conclusions: EBP is a viable and effective option for the treatment of recurrent SIH caused by cerebrospinal fluid (CSF) leaks., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Hazama et al.)

Gynecologic brachytherapy has evolved in recent years together with the technological and computer development. It has become popular to use high dose rate (HDR) and 3D volumetric planning, using computed tomography (CT) or magnetic resonance imaging (MRI), which changed the fractionation, total dose, timing of care and the conformation of treatment. Due to the real visualization of the target and organs at risk (OARS), the use of tomographic images allows to take actions and optimize the therapeutic index, escalate dose into the tumor, and protect, at the same time, OARS. the dosimetric analysis of a case of cervical cáncer FIGO IIIB treated with this premise, using blood as OARS spacer, an unprecedented procedure in the literatura, is reported below. [ABSTRACT FROM AUTHOR]

Postdural puncture headache (PDPH) is a major complication of lumber puncture or accidental dural puncture especially in patients with raised intrabdominal pressure like pregnancy, abdominal tumors etc. Many interventions have been tried to prevent and treat PDPH. None of them is 100% effective and variable success rates have been reported. We present a case of successful use of epidural saline patch to treat PDPH caused by accidental dural puncture in a 45 yrs female with large ovarian tumor.

Objectives: The aim of this current study was to analyze the possible surgical predictive factors about spontaneous intracranial hypotension (SIH) complicated with subdural hematoma (SDH)., Methods: 178 patients diagnosed with both SIH and SDH were retrospectively reviewed. All the participants were divided into as EBP group (BPG) and surgical treatment group (STG). The demographic, clinical manifestations, radiographic and treatment data of the two groups were collected and compared by the electrical medical history system., Results: The male patients accounted for the majority in the STG (77.88 %), which was significantly larger than those in the BPG(p = 0.004). Patients who regularly smoked and drunk alcohol in the STG group were significantly greater than those in the BPG group (p (smoking) = 0.049, p (drinking) = 0.014). The headache occurring in the temporal position in the STG accounted for 44.44 % which was significantly greater than those in the BPG (25.17 %, p = 0.040). The durations days of symptoms were 54.85 ± 34.78 and 33.72 ± 34.97 in the STG and BPG respectively (p = 0.005). The midline shift degree in the STG was also significantly greater than that in the BPG (p = 0.001). The largest hematoma depth in the STG was significantly greater than that in the BPG (p = 0.000). The frequency of blood patch in the STG was significantly greater than that in the BPG(p = 0022)., Conclusion: Male, unhealthy living habits, temporal headache, duration of headache, midline shift, hematoma depth and blood patch frequency were possible related factors with the poor outcome of blood patch and surgical treatment., Competing Interests: Conflicts of interest There are no conflicts of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Le blood patch constitue le traitement de référence du syndrome post ponction lombaire. Son efficacité a été démontrée par plusieurs essais randomisés comparant le BPE aux mesures conservatrices et au placebo. Il consiste en l'injection d'une quantité de sang autologue dans l'espace péridurale afin d'obturer la brèche dure-mérienne. La réalisation d'une analgésie péridurale après antécédent de blood patch est possible, malgré la persistance de questions sur les délais de retour à la normal de l'espace péridurale. Nous rapportons un cas où une analgésie péridurale a été réalisée avec succès trois semaines après un blood patch.

Background: Injection of fibrin glue mixed with blood into the epidural space to reliably and effectively treat medically refractory orthostatic headache caused by spinal cerebrospinal fluid (CSF) leaks and subsequent intracranial hypotension has recently been described. The study described in this article utilizes an analogous technique to gauge the therapeutic reproducibility of this novel technique. Methods: Eight patients with medically refractory headache resulting from intracranial hypotension caused by spinal CSF leaks received epidural injections of combined fibrin glue, autologous blood, and Isovue contrast at the L1-2 vertebral level using intermittent fluoroscopic guidance. Pre-procedure, 1-week post-procedure, and 3-month post-procedure headache pain scores were collected and used for comparison. Results: Three out of 8 patients reported relief at 1 week, although 1 of these 3 patients had returned to their baseline pain intensity at 3 months. Four patients reported no change at 1 week, though 2 of these patients had reduction of their chronic headache pain at 3 months. A single patient reported increased pain 1 week after the procedure, which persisted at 12 weeks. Overall, 4 out of the 8 patients had decreased pain scores at 3-month follow-up. Conclusions: We did not achieve a similar frequency of headache resolution as reported in prior original studies. However, a subset of patients did appear to receive substantial benefit from the combined fibrin glue-blood patching procedure. This technique may prove to be useful in medically refractory cases, including those patients who continue to have symptoms despite the prior administration of conventional epidural blood patches. [ABSTRACT FROM AUTHOR]

Patiente âgée de 24 ans, consulte aux urgences obstétricales pour des céphalées et des vomissements apparus 48 heures après une césarienne urgente faitesous rachi anesthésie. Ces céphalées étaient intenses, positionnelles, et rebelles au traitement médical pris pendant sept jours (réhydratation, repos, caféine, paracétamol). L'examen clinique n'a pas montré de déficit sensitivomoteur ou de troubles neurosensoriels, la nuque était souple, la température était de 37,2. L'examen cardiorespiratoire était sans particularités. Devant ces céphalées persistantes et invalidantes, le diagnostic d'une brèche dure mérienne a été posé et on a décidé de faire un Blood Patch. Le niveau choisi était L4-L5, en dessous de la ponction précédente avec repérage grâce à une seringue remplie d'air et l'injection de 15 ml de sang autologue prélevé au niveau du pli du coude, ce volume a été déterminé à partir d'une sensation d'une tension au niveau lombaire rapportée par la patiente. Lors de la procédure il y a eu une effraction de la dure mère avec issue du liquide céphalorachidien. Au troisième jour et devant la persistance et surtout l'aggravation des céphalées, une TDM cérébrale a été demandée et a objectivé lapneumocéphalie. L'évolution a été marquée par le tarissement spontané et complet des douleurs après 24heures d'hospitalisation en réanimationaprès laquelle la patiente est sortie à domicile. Cette observation souligne l'importance de réaliser un scanner cérébral devant une non résolution par un Blood patch des céphalées post brèche dure mérienne.

The aim of this paper is to present actual view on the role of epidural blood patch in the treatment of postdural puncture headache. Particular attention was paid to adverse effects and complications of this method and its prevention. [ABSTRACT FROM AUTHOR]

We present a case of a dural tear associated with nerve root herniation following unilateral biportal endoscopic decompression (UBED) that was successfully treated using a computed tomography-guided epidural blood patch. A 60-year-old man underwent UBED for radicular pain because of spinal stenosis at L4-5. A left partial hemilaminectomy and flavectomy were performed; however, the left dorsolateral side dura mater was torn during the procedure. TachoComb® was applied at the dural tear site, and the pain was relieved following UBED. However, 3 weeks post-UBED, the patient reported severe pain with an electric shock-like sensation in the left buttock and posterior thigh region with no other neurologic symptoms. The pain was aggravated by standing and spinal motion. Follow-up lumbar spinal magnetic resonance imaging was performed. Axial images indicated protrusion of the left S2 nerve root through the left dorsolateral side of the dura mater. The patient was further diagnosed with nerve root herniation following a dura mater tear. A computed tomography-guided epidural blood patch was performed, with successful therapeutic results. The outcome of this study indicates that a small dural tear that occurs during minimally invasive spinal surgery can be efficiently treated using an epidural blood patch prior to open surgery.

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Introduction: Quality assessment of provided healthcare is becoming a standard in numerous health institutions worldwide, which is beneficial for both the patient and the institution. In order to achieve this standard, it is necessary to develop quality indicators in all segments of healthcare. Postdural puncture headache is a common complication following neuraxial blocks, especially in obstetric anesthesia. If severe, it is a cause of emotional and psychological distress and must be treated by a blood patch., Aim: The aim of this study was to determine whether the number of these complications is reduced when blood patch frequency is monitored and analyzed and to assess the effect of countermeasures in order to improve the quality and safety of regional anesthesia in obstetrics., Methods: Before 2009 and during that year at the University Hospital Sveti Duh, there had been a large number of severe postdural puncture headaches after spinal anesthesia and epidural analgesia treated by a blood patch in 6.12% of cases. After noticing the rising number of blood patches, we decided to analyses data every year. We recorded all blood patches injected to obstetric patients within the period of nine year, from 2009 to 2018 and concurrently we introduced a set of measures to improve the quality of neuraxial blocks, such as the use of atraumatic 26 or 27-gauge pencil-point spinal needles and modern neuraxial blockade protocols. Data were collected from anesthesiology and gynecology protocols and analyzed with MedCalc software, version 18.1.2., Results: The frequency of blood patch applications has been reduced from 6.12% to 0.30%, which is statistically significant. The percentage of placed epidural catheters for vaginal birth increased from 21% in 2009 to 38% in 2018. Although not statistically significant, the number of pregnant women undergoing a caesarean section is also growing, while the total number of births is falling. The proportion of cesarean sections in spinal anesthesia varies from year to year., Discussion: A statistically significant decrease in the number of installed blood patches clearly indicates the positive effect of measures taken to improve quality, which could contribute to the growing interest of pregnant women in childbirth in epidural analgesia. The number of placed epidural catheters is increasing despite the decline in the total number of deliveries and the increase in the number of deliveries completed by cesarean section., Conclusion: Monitoring the incidence of severe post-puncture headaches treated with blood patches has shown great progress in improving the quality and safety of regional anesthesia and analgesia in our institution, so we believe that monitoring the number of blood patches could serve as an indicator of regional anesthesia and analgesia in obstetrics. Monitoring the number of blood patches shows that the frequency of post-puncture headaches does not correlate only with the type of needle or epidural catheter used for neuroaxial blocks, but is also a sensitive indicator of any deviations from the achieved standards. Furthermore, it indicates the need for careful analysis of causes in order to adopt and implement appropriate countermeasures.

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Magnetic resonance imaging in patients affected by orthostatic headache often allows the diagnosis of spontaneous intracranial hypotension (SIH). Nevertheless, in the last 5 years, the diagnostic and therapeutic strategy for spontaneous intracranial hypotension (SIH) has been significantly modified. Specifically, all invasive techniques aimed at localization and demonstration of 'spontaneous' spinal fistulas (myelography, isotopic cisternography, and so on) have been progressively abandoned. Also myelo-MR, although not an invasive exam, is no longer considered necessary to establish the most appropriate treatment. This change is due to the development and demonstration of a pathogenetic theory which considers the cerebrospinal fistula not as the primary cause of intracranial hypotension, but as the consequence of an imbalance between epidural and cerebrospinal fluid (CSF) pressures. In a consecutive series of 80 patients, we performed a standardized epidural lumbar injection of a dense compound aimed to raise the epidural pressure irrespective of the presence and site of CSF leaks. The technique used, the long-term results of this treatment and the diagnostic pathways will be discussed. [ABSTRACT FROM AUTHOR]