A small leak will sink the brain: targeted C1-C2 patching

Abstract Background Spontaneous intracranial hypotension (SIH) syndrome results from spontaneous spinal CSF leaks. The first treatment of choice consists of lumbar epidural blood patching. If this fails further imaging is mandatory to explore the possibility of targeted therapy. Case Description We describe a case of a 50-year old woman who developed spontaneous intracranial hypotension after minor blunt cervical trauma, complicated with bilateral subdural hematomas. Two lumbar epidural blood patches were unsuccessful. MRI with intrathecal gadolinium revealed a CSF leak at the C1-C2 level. A targeted blood patch via a percutaneous high thoracic epidural approach was performed and symptoms disappeared in the immediate postoperative period with a regression of the subdural hematomas on subsequent imaging. Conclusions A targeted epidural blood patch using an epidural catheter represents an elegant approach to a CSF leak at the C1-C2 region and can be successful in treating patients with severe intracranial hypotension syndrome.