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A complex Presentation of Headache after Lumbar Puncture for an Epidural Blood Patch
A complex Presentation of Headache after Lumbar Puncture for an Epidural Blood Patch
Submitted on 12 Jul 2018

Lydia Searcy MD, Cory Mansour MD, Aimee Pak, MD
Department of Anesthesiology and Perioperative Medicine at Augusta University
This poster was presented at Georgia Society of Anesthesiology
Poster Views: 809
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Poster Abstract
Post-dural puncture headache (PDPH) is a well-known clinical complication of intrathecal space instrumentation. Various modalities have been proffered for treatment of PDPH, however epidural blood patch (EBP) remains the gold-standard therapy. Notwithstanding its widespread usage, clinicians should not regard it as a benign procedure without complication. Judicious consideration should be applied to patient selection in addition to indication, timing and optimum technique to mitigate risk and improve outcomes.

Case Description:
A 27-year-old healthy G1P1 at 16 weeks was referred to Neurology for persistent, bi-frontal, throbbing headache of two-week duration with associated papilledema, nausea, vomiting, and pulsatile tinnitus. She denies aggravating or alleviating factors, photophobia, or visual changes. Brain MRI was negative for space occupying lesions. LP was significant for opening pressure of 31mm H20. She was diagnosed with Idiopathic Intracranial Hypertension (IIH) and prescribed acetazolamide 250mg daily.

The following day, she returned with a severe postural headache, vomiting, and diarrhea. Brain MRA/MRV was negative for vascular thrombosis. PDPH was suspected and she improved with analgesic and anti-emetic medications. She was instructed by Neurology to discontinue acetazolamide to allow for CSF repletion.

Five days later, she again presented with a constant, throbbing, frontal, bi-parietal headache, aggravated by coughing and sneezing with accompanying nausea and vomiting. Acute Pain Service was consulted for EBP placement. On evaluation, she denied current positional component to her headache, which was previously present. Given the complexity of her recent headache history and current presentation, EBP placement was not offered due to concern that her current headache was from worsening IHH rather than PDPH.

IIH is increased intracranial pressure in the absence of a space-occupying intracranial lesion. Symptoms include throbbing, retro-ocular headache, nausea or vomiting, and pulsatile tinnitus and visual disturbances as cranial nerves become compressed. Though the etiology is unclear, an increase in CSF or obstruction to venous drainage from the brain are proposed mechanisms.1 Treatment consists of close monitoring with therapeutic LP, pharmacologic therapy, and surgical intervention if indicated.2
PDPH is attributed to intracranial hypotension from CSF leakage into the epidural space. Decreased subarachnoid hydrostatic pressure results in subsequent meningeal and cranial nerve traction with gravity.3

1. Duffy, P.J. & Crosby, E.T. Can J Anesth (1999) 46:878.
2. Safa-Tisseront, V. Thormann, F. et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology. 2001 Aug; 95(2): 334–339. PMID:11506102.
3. Gielen M. Post dural puncture headache (PDPH): A review. Reg Anesth 1989; 14: 101–6.
4. Kranz, P.G. Amrhein, T.J. Gray, L. Rebound Intracranial Hypertension: A Complication of Epidural Blood Patching for Intracranial Hypotension. American Journal of Neuroradiology June 2014, 35 (6) 1237-1240. PMID: 24407273.
5. Pagani-Estévez GL, Chen JJ, Watson JC, Leavitt JA. Acute Vision Loss Secondary to Epidural Blood Patch: Terson Syndrome. Reg Anesth Pain Med. 2016 Mar-Apr;41(2):164-8. doi: 10.1097/AAP.0000000000000352.
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