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Background Cerebrospinal fluid-venous fistulas (CVFs) represent an underdiagnosed cause of spontaneous intracranial hypotension (SIH) that typically do not respond durably to epidural blood patching. Endovascular embolization has emerged as a minimally invasive treatment alternative to surgical ligation. We report a case of cervical CVF treated with transepidural coil embolization following failed epidural blood patch, with favorable long-term outcomes.Materials and Methods A 47-year-old male with a history of SIH treated with epidural blood patch 8 years prior presented with worsening chronic headaches associated with nausea and vomiting. Symptoms were refractory to intravenous ketorolac (15 mg × 2), metoclopramide (10 mg), ondansetron (4 mg), droperidol (2.5 mg), and diphenhydramine (25 mg). Magnetic resonance imaging (MRI) of the brain demonstrated no acute intracranial abnormality. MRI of the spine revealed spinal longitudinal extradural CSF collection extending from the cervical to lumbar spine. Digital subtraction myelography (DSM) with lumbar puncture at L3-L4 demonstrated epidural contrast stagnation with a suspected leak at the left C4-C5 level. The patient underwent catheter-assisted targeted epidural blood patch. Intraprocedural microangiography revealed a CVF at the C5 level with opacification of cervical epidural veins. Injection of autologous blood (10 mL) mixed with iodinated contrast (2 mL) at the C5-C6 level demonstrated contrast opacification into the fistula without blood stagnation at the leak site. Given failure of targeted blood patching, transepidural coil embolization of the CVF was performed with deployment of multiple detachable coils until complete fistula obliteration was achieved.Results Post-embolization microangiography confirmed complete obliteration of the CVF with loss of venous opacification. The patient experienced significant improvement in headaches post procedurally. At follow-up, he reported recurrent headaches with tinnitus without positional component. Lumbar puncture under fluoroscopic guidance demonstrated opening pressure of 18 cm H 2O, increasing to 40 cm H2O with Valsalva maneuver, consistent with rebound intracranial hypertension. The patient was initiated on acetazolamide with resolution of symptoms. At 1-year follow-up, the patient remained clinically well without recurrence of SIH symptoms.Conclusions This case demonstrates the technical feasibility and durable efficacy of transepidural coil embolization for cervical CVF refractory to targeted epidural blood patching. Rebound intracranial hypertension is a recognized complication following successful CVF treatment and should be anticipated in postprocedural management. Long-term follow-up confirms sustained clinical improvement following endovascular intervention for this challenging subset of SIH.Disclosures G. Kaur: None. S. Gillani: None. H. Tolba: None. R. Fakhi: None. A. Qureshi: None.Abstract E-294 Figure 1-2