Spontaneous CSF leak treated with percutaneous CT-guided fibrin glue

Spontaneous intracranial hypotension (SIH) is characterized by CSF hypovolemia usually occurring secondary to a spontaneous breech in the spinal dura mater. While patients with SIH often recover spontaneously or with autologous epidural blood patch (EBP), up to 1/3 of patients fail to respond to repeated EBP. While surgical therapy can be curative in these cases if the leak can be localized, the cost, morbidity, and difficulty identifying the site of the CSF leak during surgery makes this option less than optimal.¹ We report a patient with a persistent symptomatic CSF leak who recovered following a percutaneous CT-guided fibrin glue injection at the site of a CSF leak.

Case report.

A 44-year-old nurse was evaluated for a 3-month history of chronic daily headache. Three months prior to presentation, the patient developed five discrete episodes of exertional headache over a 10-day period. Each episode resolved completely after a night's sleep. In between episodes, she was headache-free. Over the next week, she avoided physical activity and remained headache-free.

One week after the last episode of exertional headache, she spontaneously developed an occipital-nuchal headache that initially appeared by mid-afternoon but eventually began to appear shortly after rising in the morning. She remained bedbound and disabled with headache.

MRI of the brain with and without contrast, performed 1 month after headache onset, was normal. An empiric 15 mL autologous lumbar EBP provided relief for 24 hours. Subsequently a lumbar puncture, CT myelogram, and radionuclide cisternogram were reported to be normal except an opening pressure of 40 mm H₂O. The patient underwent another 10 mL autologous lumbar EBP that provided headache relief for only 12 hours.

Three months after headache onset, the patient was evaluated at our institution. Physical examination was unremarkable as was the outside brain MRI. MRI of the spine revealed the spinal subarachnoid space to be markedly reduced circumferentially by prominent extra-arachnoid CSF collection surrounding the thecal sac. CT myelography confirmed the contraction of the thecal sac in the cervical and thoracic spinal canal and extravasation of contrast material from an extra-arachnoid fluid collection along the root sleeves of multiple cervical nerve (figure, A). After a 2-hour delay, a dense collection of contrast material was demonstrated outside of the thecal sac in the right neural foramen of T3-T4 with the patient in the right lateral decubitus position (figure, B).

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Figure. (A) Diffuse extra-arachnoid fluid collection seen on axial CT image after myelography. (B) Delayed extravasation of myelographic dye at the right T3 root with patient in the right lateral decubitus position.

After considerable discussion, the decision was made not to proceed with another EBP at the high thoracic spinal region. Under CT guidance, 3.5 mL of Tisseel (Baxter Healthcare Corp., Deerfield, IL) was injected, using an 18-guage needle, into the epidural space surrounding the T2 nerve root and theca. The procedure was repeated using 4 mL of Tisseel at the level of T3. The procedure was performed in the outpatient setting by a neurosurgeon (N.P.). Other than mild short-lasting axillary discomfort, the procedure was tolerated well and without complications. The patient's headache improved within hours after the procedure and disappeared within 24 hours. She has remained free from headache 6 months after the procedure.

Discussion.

This report describes a patient with a spontaneous CSF leak presenting initially with exertional headaches with orthostatic features, followed by headaches that appeared in the afternoon (second half of the day headache) that gradually evolved into a persistent chronic daily headache. Delayed CT myelography demonstrated a CSF leak at the T3 level. After failure to respond to repeated EBP, CT-guided percutaneous injection with fibrin glue provided prompt and sustained relief of headache and associated symptoms.

Fibrin glue (also known as fibrin sealant) is a preparation that mimics the final stages of blood coagulation by forming a stable physiologic fibrin clot that can assist both hemostasis and wound healing.² There are recent reports of patients with spontaneous CSF leaks responding to targeted fibrin sealant injection at the site of a CSF leak in the cervical and thoracic region.^3,4

CT-guided injection of fibrin glue at the site of a spinal CSF leak may obviate the need for surgery. Complete and long-lasting benefit has now been reported in five of seven treated cases, including this case. With more experience and appropriate patient selection, this technique may be an important alternative to surgical therapy for patients with intractable SIH secondary to persistent CSF leaks.