Percutaneous and Endovascular Treatment of Spontaneous Intracranial Hypotension and Related Cerebrospinal Fluid Disorders.

Cerebrospinal fluid (CSF) leaks, whether spontaneous or iatrogenic, can lead to debilitating post-dural puncture or intracranial hypotension-related headaches characterized by orthostatic symptoms. Epidural blood patching (EBP) has become a mainstay treatment once conservative measures (bed rest, hydration, and caffeine) fail. An EBP involves injecting autologous blood into the epidural space to seal dural defects, with success rates ranging from ∼70%-90% for post-dural puncture (iatrogenic) leaks but only ∼30% for spontaneous leaks on the first attempt. For patients with persistent CSF leakage despite repeat EBPs (refractory cases), fibrin sealant ("fibrin glue") injections provide an alternative minimally invasive therapy. Fibrin sealants polymerize into a clot that can patch the dural tear and withstand normal CSF pressures. Several case series report that targeted fibrin glue therapy (alone or combined with blood) yields additional successes, especially in patients who have failed standard blood patches. However, outcomes vary widely, with success rates for fibrin patches in the literature ranging from as low as ∼12%-30% in complex spontaneous leaks to as high as 80%-90% in some cohorts. This review provides a comprehensive overview of CSF leak etiologies and management, focusing on the techniques, efficacy, and indications of EBPs and fibrin glue sealant patches, as well as current evidence and evolving strategies to optimize treatment of these challenging cases.