Background: Epidural blood patch (EBP) is a therapeutic procedure used to treat post dural puncture headache and liquor hypotension headache (1,2). It involves the administration of autologous blood in the epidural space which, through a still not fully explained mechanism, works as a patch of cerebrospinal fluid (CSF) leaks, raising epidural space pressure and causing an inflammatory response that will lead to healing of the leaking spots. There are some reported cases of the use of this procedure in children, including under general anesthesia (blind blood patch) (3). Intrathecal (IT) chemotherapy is another increasingly used procedure used in the treatment of some forms of cancer. These procedures involving repeated lumbar punctures (LP), that may form CSF fistula, leading to liquor hypotension and related symptoms. 

Case report: Ten-year-old female, diagnosed with Acute Lymphoblastic Leukemia – group AR2 (ALL–T AR2), treated with IT chemotherapy. After various unsuccessful LP, without CSF exit, she developed symptomatic focal crisis. CT scan revealed venous thrombosis of the posterior sagittal sinus, without hydrocephalus signs. After introducing an intracranial pressure catheter, the patient repeated the CT scan revealing a marked shift of the structures of the midline, therefore she underwent an urgent decompressive craniectomy. There was no improvement in the clinical status after surgery. Dorsal spine MR myelography revealed a CSF collection in the epidural space from T4 to the lumbar area with an increase of CSF in the lumbar cistern. A multidisciplinary team decided to perform a blood patch. The procedure was performed by a trained anesthesiologist: after finding the epidural space on the L4-L5 level, we used a Tuohy 20 needle and injected 8mL of autologous venous blood, collected from the saphenous vein of the left leg, with no resistance to the injection. We used the proper aseptic conditions and there were no complications. The patient had a favorable clinical and imagological evolution in the 24 hours after the procedure.
Discussion: There are no case reports to our knowledge regarding blood patch use in children with LCR hypotension with clinical instability.  This case proves that blind blood patch may be a possibility in such cases.


01 / Epidural blood patch for the treatment of post intrathecal chemotherapy liquor hypotension in a 10-year-old