Chronic CSF leak into the peritoneal cavity shown by radionuclide cisternography: Successful treatment with an epidural blood patch

Cerebrospinal fluid (CSF) leak is a well-documented complication of a spinal puncture that is performed for both diagnostic and therapeutic purposes, The use of radionuclide cisternography in the diagnosis of cerebrospinal fluid leaks is well established and has been reported as effective in securing the diagnosis of CSF fluid leak after lumbar puncture. The use of an epidural blood patch is effective in repairing 96-98% of such leaks and is thought to work by both forming a dural plug and by reducing the volume of the subarachnoid space. The authors report a 7-year-old boy who had recurrent medulloblastoma and developed a CSF leak into the peritoneal cavity after a course of intrathecal 4-hydroxy-cyclophosphamide. An initial Tc-99m human serum albumin CSF flow study before therapy was normal. A further course of intrathecal therapy was planned; however, delayed images on a repeat CSF flow study showed tracer activity throughout the abdomen intraperitoneally, indicating a leak of CSF from the thecal sac presumed to be at the sight of the recent spinal puncture. A CT myelographic study showed maximal epidural contrast at the L4-5 level, which extended from L4 through the S1 level. After 5 months of continual leak, an epidural blood patch was performed using autologous blood. A repeat CSF flow study performed 2 weeks after this procedure showed resolution of the CSF leak.