Epidural Blood Patch in Patients With Hematologic Malignancies: A Case Series

Post-dural puncture headaches (PDPH) are caused by cerebrospinal fluid (CSF) leaks that occur after a lumbar puncture (LP). Epidural blood patch (EBP) is an effective treatment option for patients with PDPH in whom conservative treatment fails. Special consideration has to be taken if the patient is affected by any hematological malignancy, due to the fact that EBP carries a theoretical risk of seeding the malignancy into the neuroaxis. The frequent occurrence of immunocompromised status and thrombocytopenia in this patient population warrants individual assessment prior to decision-making. The purpose of our study was to demonstrate that EBP is a safe treatment option if used in the right clinical setting.

In our study, we report the imaging and clinical findings of five patients with hematologic malignancies who developed PDPH following LP. All patients failed to respond to conservative treatment and required EBP.

The EBP was successfully performed in all five patients. The preprocedural brain and spine MRI findings were concerning for CSF leak, demonstrating subdural fluid collections, pachymeningeal enhancement, and brain sagging. All patients responded favorably to EBP with the resolution of symptoms. In the long-term follow-up, none of them developed postprocedural infections or neuroaxis tumor seeding. Thrombocytopenia did not result in failure of the procedure or any bleeding complications.

EBP is effective in treating conservative therapy-refractory PDPH in a patient population with underlying hematologic malignancies. Due to the increased risks of infection in the setting of immunosuppression, compromised coagulation status related to underlying malignancy, and possible tumor seeding to the neuroaxis, the procedure and possible associated risks should be discussed thoroughly with the patient and family.

We noticed in our practice that there is a lack of deep understanding of a specific patient population affected by hematologic malignancies developing postdural puncture headaches after an LP. As of today, there are no well-established guidelines regarding this specific situation, and every proceduralist has to make a decision whether they feel comfortable performing an EBP when conservative treatment fails, with the possible risk of disease spreading, infection, and bleeding. With our paper, we offered insights into our practice and results, and hope to serve as a helpful resource for proceduralists who are facing a similar clinical setting.