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Liquorverlustsyndrom

Indikation, Technik und Ergebnisse der Behandlung mit „blood patch“

Cerebrospinal fluid leakage

Indications, technique and results of treatment with a blood patch

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Zusammenfassung

Hintergrund

In den meisten Fällen ist ein Liquorverlustsyndrom iatrogen durch Lumbalpunktionen, Periduralanästhesien oder operative Eingriffe an der Wirbelsäule bedingt. Durch verbesserte diagnostische Möglichkeiten werden jedoch auch spontane Liquorverlustsyndrome mit zunehmender Häufigkeit diagnostiziert, deren Ursache oft nicht eindeutig zu klären ist.

Methoden

Zur radiologischen Diagnosesicherung und zur Lokalisierung des Liquorlecks stehen mit der Postmyelo-CT, der 111Indium-Radioisotopenzisternographie und der (Myelo-)MRT mehrere Verfahren mit unterschiedlichen Sensitivitäten zur Verfügung. Nach unserer eigenen Erfahrung ist eine primär nativdiagnostische MRT mit fettsaturierten T2-Sequenzen in vielen Fällen bereits diagnostisch ausreichend, um das Liquorleck und seine Lokalisation zu sichern. In den übrigen Fällen ist die Durchführung einer ergänzenden Postmyelo-CT oder alternativ einer Myelo-MRT empfehlenswert. Bei manchen Patienten mit spontanem Liquorverlustsyndrom finden sich dabei mehrere Liquorlecks auf unterschiedlichen Höhen.

Leitsymptom ist in den meisten Fällen ein lageabhängiger orthostatischer Kopfschmerz. Während das postpunktionelle Syndrom unter Bettruhe und medikamentöser Therapie oft selbstlimitierend ist, bedarf es beim spontanen Liquorverlustsyndrom meist einer Blood-patch-Therapie. Der lumbale „blood patch“ kann in der Regel problemlos unter Durchleuchtungskontrolle erfolgen. Bei einem „blood patch“ an der HWS oder BWS wird aus Sicherheitsgründen eine CT-gesteuerte Durchführung empfohlen, um eine streng epidurale Blutverteilung zu gewährleisten und eine Myelonverletzung sicher zu vermeiden.

Trotz hoher Wirksamkeitsrate des ersten „blood patch“ von bis zu 85 % ist in manchen Fällen eine teils mehrfache Wiederholung erforderlich. Ein gezielter „blood patch“ ist bei lokalisierbarem Liquorleck einer ungezielten Blood-patch-Therapie grundsätzlich vorzuziehen. Bei nicht eindeutig zu lokalisierendem Liquorleck kann jedoch auch ein Therapieversuch mit lumbalem „blood patch“ unter Kopftieflagerung unternommen werden. Bei erfolgreichem „blood patch“ findet sich eine schnelle Rückbildung von Hygromen und duralem Enhancement im Kopf, während epidurale Hygrome an der Wirbelsäule, trotz Beschwerdefreiheit des Patienten, noch über Monate persistieren können.

Schlussfolgerung

Insgesamt stellt der „blood patch“ eine technisch relativ einfache und sicher durchzuführende Methode mit hoher Wirksamkeitsrate dar und ist sowohl beim spontanen Liquorverlustsyndrom als auch beim therapierefraktären postpunktionellen Syndrom die Therapie der Wahl.

Abstract

Background

In most cases cerebrospinal fluid (CSF) leaks are iatrogenic and caused by medical interventions, such as lumbar puncture, peridural anesthesia and surgical interventions on the spine, However, spontaneous cerebral hypotension is currently detected more frequently due to improvements in diagnostic possibilities but often the cause cannot be clarified with certainty.

Methods

There are various diagnostic tools for confirming the diagnosis and searching for the site of CSF leakage, such as postmyelography computed tomography (postmyelo-CT), indium111 radioisotope cisternography and (myelo) magnetic resonance imaging (MRI), which show different sensitivities. In accordance with own experience native MRI with fat-saturated T2-weighted sequences is often sufficient for diagnosing CSF leakage and the site. For the remaining cases an additional postmyelo-CT or alternatively myelo-MRI is recommended. In some patients with spontaneous cranial hypotension multiple CSF leaks are found at different spinal levels. The main symptom in most cases is an orthostatic headache. While post-puncture syndrome is self-limiting in many cases, spontaneous CSF leakage usually requires blood patch therapy. A lumbar blood patch can be safely carried out under guidance by fluoroscopy. In the case of a cervical or dorsal blood patch, CT guidance is recommended, which ensures epidural application of the blood patch and minimizes the risk of damaging the spinal cord. Despite a high success rate at the first attempt with a blood patch of up to 85 %, some cases require repeating the blood patch. A targeted blood patch of a CSF leak should generally be favoured over a blindly placed blood patch; nevertheless, if a CSF leak cannot be localized by CT or MRI a therapeutic attempt with a lumbar blood patch can be carried out. After a successful blood patch intracranial hygromas and pachymeningeal enhancement in the head show fast regression; however, epidural hygromas of the spine can persist for a period of several months, even though patients are already free of symptoms.

Conclusion

In total, blood patch therapy is a safe and technically relative simple method with a high success rate. Therefore, it represents the therapy of choice in patients with spontaneous cerebrospinal fluid leakage as well as in cases of post-lumbar puncture syndrome refractory to conservative therapy.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. A. Gottschalk gibt an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Abteilung Neuroradiologie, Krankenhaus Nordwest, Steinbacher Hohl 2–26, 60488, Frankfurt am Main, Deutschland

    A. Gottschalk

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Gottschalk, A. Liquorverlustsyndrom. Radiologe 55, 471–478 (2015). https://doi.org/10.1007/s00117-014-2804-6

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  • DOI: https://doi.org/10.1007/s00117-014-2804-6

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