Clinical trial NCT03276975: A Randomized Trial of CT Fluoroscopy-guided Targeted Autologous Blood and Fibrin Glue Patching for Treatment
Official title: A Randomized Trial of CT Fluoroscopy-guided Targeted Autologous Blood and Fibrin Glue Patching for Treatment of Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension.
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE2
Conditions: Cerebrospinal Fluid Leaks
Keywords: CT fluoroscopy
epidural patching
spontaneous intracranial hypotension
Lead sponsor: Duke University
Sponsor class: OTHER
First posted: 2017-09-08
Enrollment: 15
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The goal of this randomized controlled trial (RCT) is to compare the efficacy of CT fluoroscopy-guided targeted epidural patching for treatment of imaging-confirmed spinal CSF leaks to that of a simulated procedure without patching material in patients with spontaneous intracranial hypotension.

Detailed description: Spontaneous intracranial hypotension (SIH) is a condition caused by non-iatrogenic spinal CSF leaks that classically presents with orthostatic headaches. These headaches, in conjunction with other presenting symptoms such as nausea, diplopia, tinnitus, and cognitive deficits, often result in profound disability. SIH is considerably underreported due to pervasive misdiagnosis. Thus, while the estimated annual incidence is reported to be 5 in 100,000, the actual number is likely considerably greater.

The current standard-of-care treatment for SIH cases that are refractory to conservative measures (i.e. bed rest and hydration) is percutaneous epidural blood patching (EBP) of the spinal CSF leak. Percutaneous EBP can be performed in several ways: 1) with or without imaging guidance, 2) targeted to a site of known or suspected CSF leak or non-targeted, and 3) with or without the addition of fibrin glue sealant.

The leading theory for the mechanism behind percutaneous EBP treatment of SIH is that it creates a durable seal of the CSF leak resulting in normalization of CSF hydrodynamics and a resultant diminution in symptoms. Fibrin glue, a sealant used for treatment of unintended durotomies during neurosurgery, is thought to improve the likelihood of a successful patch over patches containing blood alone. Therefore, imaging-guided targeted delivery of patching material containing both blood and fibrin glue directly to the site of CSF leak, a novel therapy, is presumed to be the optimal therapy. For this reason, this procedure has become standard-of-care at many tertiary-care institutions over the past several years.

Our group has extensive experience with CT fluoroscopy-guided targeted blood and fibrin glue patching of proven CSF leaks in SIH patients. However, significant uncertainty remains with regard to the efficacy of this procedure due to a paucity of outcomes data and the absence of any prospective RCTs. In fact, nearly all of the current evidence for the treatment of SIH is found in the form of retrospective chart reviews. Given the growing recognition of SIH, the fact that a known subset of patients will have spontaneous resolution of symptoms, and the absence of clear evidence to guide treatment, there is a critical need to evaluate the efficacy of targeted patching with blood and fibrin glue with a prospective RCT. Fulfilling this unmet need forms the basis for this proposal. While determining the efficacy of the other types of EBPs is also important, we aim to begin by evaluating the efficacy of the presumed optimal therapy.

Eligibility criteria: Inclusion Criteria:

* Adult patients meeting International Classification of Headache Disorders 3rd Edition (ICHD-3) criteria for a diagnosis of SIH (Table 1) who have had a contrast-enhanced brain MRI and a myelogram confirming the presence of a CSF leak will be recruited from the Duke Radiology spine intervention clinic \[25\]

Exclusion Criteria:

* recent (i.e., \< 2 weeks) blood patch
* contraindication or inability to undergo the procedure
* inability to provide informed consent
* expected inability to complete follow-up assessment
* a contraindication to receiving contrast material (precluding an epidurogram)
* contraindication to receiving fibrin glue (i.e., allergy).

Primary outcomes:
measure: Change in Median (Headache Impact Test-6) HIT-6 Score From Baseline
timeFrame: Baseline, 1 month
Secondary outcomes:
measure: Change in Median HIT-6 Score From Baseline
timeFrame: Baseline, 2 weeks, 4 months
measure: Reduction in Median Migraine Disability Assessment (MIDAS) Score From Baseline
timeFrame: Baseline, 2 weeks, 1 month, 4 months
measure: Change in Median NRS Score From Baseline
timeFrame: Baseline, 2 weeks, 1 month, 4 months
measure: Change in Median EQ-5D (European Quality of Life-5 Dimensions) Score From Baseline
timeFrame: Baseline, 2 weeks, 1 month, 4 months
measure: Change in Median WPAI (Work Productivity and Activity Impairment) Score From Baseline
timeFrame: Baseline, 2 weeks, 1 month, 4 months
measure: Change in PGIC (Patient Global Impression of Change) Score From Baseline
timeFrame: Baseline, 2 weeks, 1 month, 4 months
Other outcomes:
Locations:
city: Durham
country: United States
facility: Duke University
state: North Carolina
Study officials:
References: