Thoracic epidural blood patch with CT conformation used in treatment of recurrent subdural hematoma with spontaneous intacranial hypotension

Introduction: CSF Leakage is a primary cause of SIH. SIH with SDH is a rare case but with morbid complication. Incidence of 1/50000 SDH present with SIH. Unfamiliarity with SIH among physician and unusual clinical, radiological presentation delays diagnosis. Case Summary: 54 year old male with Diabetes, OSA and HTN presented with holocranial headache, vomiting and photophobia with no neurological sign. Urgent brain CT and venogram showed bilateral SDH with downward displacement of brainstem and distended venous sinuses s/o SIH. MRI Brain and myelography confirmed bilateral SDH and site of CSF leak could not be detected. Diagnosis of intracranial hypovolemic syndrome was made. Patient underwent bilateral burr hole drainage of SDH, blind Lumbar EBP was tried twice with no success. CT myelogram repeated still not s/o any leaks. EBP tried with the 18G epidural needle in T11-T12, under aseptic conditions 30 cc blood slowly injected in same space and catheter removed CT confirmation done, dressing and head low given. CT brain and MRI repeated shows decreased SDH, cerebral edema and midline shift with increased in cistern size and improvement in sensorium of the patient over the time. Conclusion: Management of SDH should focus on correction of underlying SIH. CT guided epidural blood patching in the thoracic or cervical spine should be considered for SIH when lumbar blood patching fails.