Meningeal puncture headache

A patient received a difficult epidural placement for an open colectomy. A couple of days later, the patient complains of a headache that occurs within 15 minutes of getting up out of bed. In addition, she feels nauseated and her vision is blurred. Upon examination, the proceduralist notices a deviation of the eyes in a horizontal plane and an inability for the patient to abduct both eyes. What is the next best course of management of her headache?

A. Offer her an immediate blood patch, as her neurologic signs are concerning for abduscens palsy.
B. Epidural blood patch is a high risk procedure so intravenous caffeine, hydration, and systemic analgesics should be offered first.
C. Give intravenous cosyntropin 1mg. If this fails, then offer epidural blood patch after 24 hours.
D. Consult neurologist, as some of her symptoms are atypical of a postdural puncture prior to proceeding with any intervention.

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Correct Answer: A

Explanation:

Postdural puncture headaches are a result of intracranial hypotension after CSF leak. It is frontal and occipital in location with a positional component (traditionally worsened within 15 minutes of upright position and improved within 15 minutes of supine positions). These headaches may be accompanied by nausea/vomiting, neck stiffness, visual disturbances, and hearing alterations within lower frequencies, and usually manifest within 5 days of dural penetration. PDPH may be improved by caffeine (oral caffeine has good bioavailability), rest, and hydration, though these benefits are transitory at best. Intravenous cosyntropin for prophylactic reduction in the need for an epidural blood patch has been studied in a small randomized, placebo-controlled study (n=90) in parturients after inadvertent dural puncture and showed a roughly 10 hour increase in time from dural puncture to manifestations of PDPH as well a reduction in epidural blood patch requirements (28.9% vs 11%). Intravenous cosyntropin for management of PDPH has been noted in a case report by Carter et al and a small RCT by Hanling et al. Neuraxial opioids can help improve the perception of pain. The abduscens nerve, due to its course in the brain, is easily affected by intracranial volume loss, leading to subsequent diplopia. It appears that early blood patch in these patients would result in a greater likelihood of relieving diplopia.

References:

Hofer JE, Scavone BM. “Cranial nerve VI palsy after dural-arachnoid puncture.” Anesth Analg 2015;120:644-6.

Bechard P, Perron G, Larochelle D, Lacroix M, Labourdette A, Dolbec P. “Case report: epidural blood patch in the treatment of abduscens palsy after dural puncture.” Can J Anesth 2007;54(2):146-50.

Gaiser RR. “Postdural Puncture Headache: An evidence-based approach.” Anesthesiology Clin 2017;35:157-67.

Halker RB, Demaershalk BM, Wellik KE, Wingerchuk DM, Rubin DI, Crum BA, Dodick DW. “Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth.” The Neurologist 2007;13:323-7.

Hakim SM. “Cosyntropin for prophylaxis against postdural puncture headache after accidental dural puncture.” Anesthesiology 2010;113(2):413-20.

Carter BI, Pasupuleti R. :Use of intravenous cosyntropin in the treatment of postdural puncture headache. Anesthesiology 2000;92:272-4.

Hanling SR, Lagree JE, Colmenar DH, Quiko AS, Drastol CA. “Intravenous Cosyntropin versus epidural blood patch for treatment of postdural puncture headache.” Pain Medicine 2016;17:1337-42.

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