Outcomes of CT-Guided Targeted Epidural Patching For Lateral Dural Tears In Spontaneous Intracranial Hypotension: A Multicenter Retrospective Cohort Study

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension (SIH) due to lateral dural tears with spinal longitudinal extradural fluid collections (SLECs) can cause disabling orthostatic headaches. While epidural patching is commonly used as first-line treatment, outcomes specific to lateral dural tears have not been well characterized. We aimed to evaluate clinical and radiologic outcomes following CT-guided patching for lateral dural tears and assess whether anatomic or procedural factors— including presence of a herniated arachnoid pouch, patch volume, material, or approach—influence treatment success.

MATERIALS AND METHODS: This was a retrospective multicenter cohort study of patients with lateral dural tears treated with CT-guided epidural patching between December 2013 and March 2025. Demographics, leak characteristics, patching details, and clinical and imaging outcomes were collected. The presence of herniated arachnoid pouches on spine MRI and pre/post-treatment Bern scores were recorded. Associations between clinical resolution, SLEC resolution, and procedural variables were analyzed using univariate methods.

RESULTS: Fifty-six patients (mean age 38.7 ± 11.7 years; 80% female) were included. Mean pretreatment Bern score was 6.6 ± 2.3; no patients had superficial siderosis. Clinical resolution occurred in 20/56 (35.7%), and SLEC resolution in 10/40 (25%) on post-patch spine MRI. A herniated arachnoid pouch was present in 69.7% and associated with lower SLEC resolution (30% vs. 80%, p=0.003). Patch type, volume, transforaminal approach, and needle placement into the herniated pouch were not associated with outcomes. Post-patch Bern scores were lower among those with clinical resolution (0.9 ± 1.1 vs. 2.6 ± 2.5, p=0.046). Of 11 patients with complete clinical improvement who had post-patch spine MRI, 5 (45.5%) had persistent SLECs.

CONCLUSIONS: CT-guided patching led to complete symptom resolution in roughly one-third of patients with lateral dural tears. Herniated arachnoid predicted lower SLEC resolution, while procedural variables were not predictive of outcome. A subset of patients improved clinically despite persistent extradural fluid, emphasizing the need for long-term monitoring.

ABBREVIATIONS: SIH＝ spontaneous intracranial hypotension; SLEC = spinal longitudinal extradural fluid collection